Healthcare Provider Details

I. General information

NPI: 1548248065
Provider Name (Legal Business Name): LOWELL ANDREW GORDON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/04/2006
Last Update Date: 10/22/2025
Certification Date: 10/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

661 W 1ST ST STE G
TUSTIN CA
92780-2939
US

IV. Provider business mailing address

661 W 1ST ST STE G
TUSTIN CA
92780-2939
US

V. Phone/Fax

Practice location:
  • Phone: 714-665-9890
  • Fax: 714-665-9891
Mailing address:
  • Phone: 714-665-9890
  • Fax: 714-665-9891

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number96-256
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA44724
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: