Healthcare Provider Details

I. General information

NPI: 1952309056
Provider Name (Legal Business Name): SUSANNA REBA GORDON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2005
Last Update Date: 12/15/2020
Certification Date: 12/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6939 PALM CT
RIVERSIDE CA
92506-2815
US

IV. Provider business mailing address

PO BOX 512185
LOS ANGELES CA
90051-0185
US

V. Phone/Fax

Practice location:
  • Phone: 951-683-6771
  • Fax:
Mailing address:
  • Phone: 626-775-3514
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number49114
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number34232
License Number StateIA
# 3
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License NumberG84560
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: