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1013101161

NPI Code Detail

MEDICARE: DR. KENYETTA MICHELLE GORDON MD

MEDICARE: DR. KENYETTA MICHELLE GORDON MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	19863	NV
2	207Q00000X	Family Medicine Physician	E-6423	AR
3	207Q00000X	Family Medicine Physician	C186176	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1013101161
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KENYETTA MICHELLE GORDON MD

Provider Business Mailing Address
First Line	:	1600 WEEOT WAY
Second Line	:
City	:	ARCATA
State	:	CA
Zip	:	95521-4734
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1675 NORTHCREST DR
Second Line	:
City	:	CRESCENT CITY
State	:	CA
Zip	:	95531-8928
Country	:	US
Telephone Number	:	707-464-2750
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/31/2007
Last Update Date	:	05/26/2023

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Directions to “ DR. KENYETTA MICHELLE GORDON MD” Practice Location

Language	Start Address	Practice Location

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