Healthcare Provider Details

I. General information

NPI: 1255409512
Provider Name (Legal Business Name): DOUGLAS MARK GORDON D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/02/2006
Last Update Date: 07/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20700 VENTURA BLVD. STE. 130
WOODLAND HILLS CA
91364-6277
US

IV. Provider business mailing address

20700 VENTURA BLVD. STE. 130
WOODLAND HILLS CA
91364-6277
US

V. Phone/Fax

Practice location:
  • Phone: 818-345-2660
  • Fax: 818-206-9471
Mailing address:
  • Phone: 818-345-2660
  • Fax: 818-206-9471

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number23821
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: