=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518302777
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GORDON GUNN M.D INC A MEDICAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/01/2013
-----------------------------------------------------
Last Update Date | 05/01/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 E VALENCIA MESA DR # 215
-----------------------------------------------------
City | FULLERTON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92835-3813
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-912-2211
-----------------------------------------------------
Fax | 714-213-8750
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 E. VALENCIA MESA DR #215
-----------------------------------------------------
City | FULLERTON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92835-3800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-912-2211
-----------------------------------------------------
Fax | 714-213-8750
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | JUDITH WERTS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 714-912-2211
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | C27175
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------