Provider Demographics
NPI:1700981263
Name:WHITE, GORDON VAL (PH D)
Entity type:Individual
Prefix:MR
First Name:GORDON
Middle Name:VAL
Last Name:WHITE
Suffix:
Gender:M
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 EL CAMINO REAL
Mailing Address - Street 2:SUITE 203
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92054
Mailing Address - Country:US
Mailing Address - Phone:760-439-0911
Mailing Address - Fax:760-439-0714
Practice Address - Street 1:2101 EL CAMINO REAL
Practice Address - Street 2:SUITE 203
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92054
Practice Address - Country:US
Practice Address - Phone:760-439-0911
Practice Address - Fax:760-439-0714
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY4394103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP4394Medicare ID - Type Unspecified