MEDICARE: DR. JEOFFRY BRUCE 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	G19279	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
2	G19279	OTHER	CA	LICENCE #

General Provider Information

NPI Number	:	1649263682
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEOFFRY BRUCE GORDON MD

Provider Business Mailing Address
First Line	:	823 GATEWAY CENTER WAY
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92102-4541
Country	:	US
Telephone Number	:	619-525-2300
Fax Number	:	619-906-4564

Provider Business Practice Location Address
First Line	:	1947 CABLE ST
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92107-2807
Country	:	US
Telephone Number	:	619-223-7164
Fax Number	:	619-223-5443

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

Provider Enumeration Date	:	08/24/2005
Last Update Date	:	03/07/2023

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