Healthcare Provider Details

I. General information

NPI: 1992710826
Provider Name (Legal Business Name): OCEAN BEACH MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2006
Last Update Date: 06/18/2008
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

1947 CABLE ST
SAN DIEGO CA
92107-2807
US

V. Phone/Fax

Practice location:
  • Phone: 619-223-7164
  • Fax: 619-223-5443
Mailing address:
  • Phone: 619-223-7164
  • Fax: 619-223-5443

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: DR. JEOFFRY BRUCE GORDON
Title or Position: OWNER
Credential: MD
Phone: 619-223-7164