Provider Demographics
NPI:1144342601
Name:GORDON, DANIEL MARK (MD)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:MARK
Last Name:GORDON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 CALIFORNIA BLVD STE P
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-2590
Mailing Address - Country:US
Mailing Address - Phone:805-544-8709
Mailing Address - Fax:805-544-7809
Practice Address - Street 1:620 CALIFORNIA BLVD STE P
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-2590
Practice Address - Country:US
Practice Address - Phone:805-544-8709
Practice Address - Fax:805-544-7809
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG427492084P0800X, 2084P0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Not Answered2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG42749Medicare UPIN
CAG42749Medicare ID - Type Unspecified