1255487518 NPI number — GORDON OMAR MATHESON M.D., PH.D.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255487518 NPI number — GORDON OMAR MATHESON M.D., PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MATHESON
Provider First Name:
GORDON
Provider Middle Name:
OMAR
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D., PH.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1255487518
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
341 GALVEZ ST
Provider Second Line Business Mailing Address:
ARRILLAGA MC 6150
Provider Business Mailing Address City Name:
STANFORD
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94305-6106
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
650-723-2257
Provider Business Mailing Address Fax Number:
650-725-2607

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
341 GALVEZ ST
Provider Second Line Business Practice Location Address:
ARRILLAGA MC 6150
Provider Business Practice Location Address City Name:
STANFORD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94305-6106
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
650-723-2257
Provider Business Practice Location Address Fax Number:
650-725-2607
Provider Enumeration Date:
01/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 204C00000X , with the licence number:  C43343 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2025 www.npivalidator.com