Healthcare Provider Details

I. General information

NPI: 1649263682
Provider Name (Legal Business Name): JEOFFRY BRUCE GORDON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2005
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1947 CABLE ST
SAN DIEGO CA
92107-2807
US

IV. Provider business mailing address

823 GATEWAY CENTER WAY
SAN DIEGO CA
92102-4541
US

V. Phone/Fax

Practice location:
  • Phone: 619-223-7164
  • Fax: 619-223-5443
Mailing address:
  • Phone: 619-525-2300
  • Fax: 619-906-4564

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG19279
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: