Healthcare Provider Details

I. General information

NPI: 1275637282
Provider Name (Legal Business Name): CHRISTY LEE GORDEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33353 YUCAIPA BLVD
YUCAIPA CA
92399-2018
US

IV. Provider business mailing address

PO BOX 8188
REDLANDS CA
92374-1388
US

V. Phone/Fax

Practice location:
  • Phone: 909-790-7900
  • Fax: 909-790-7058
Mailing address:
  • Phone: 909-790-5071
  • Fax: 909-790-5774

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG42484
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: