Provider Demographics
NPI:1548248065
Name:GORDON, LOWELL (MD)
Entity type:Individual
Prefix:DR
First Name:LOWELL
Middle Name:
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 1:3710 LOTUS DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92106-1139
Mailing Address - Country:US
Mailing Address - Phone:505-660-7197
Mailing Address - Fax:
Practice Address - Street 1:661 W 1ST ST STE G
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-2939
Practice Address - Country:US
Practice Address - Phone:714-665-9890
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-04
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM96-256208000000X
CAA44724208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
F17208Medicare UPIN