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General NPI Number Information
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NPI Number | 1992710826
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Entity Type | Organization
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Legal Business Name | OCEAN BEACH MEDICAL GROUP
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Dates
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Enumeration Date | 07/29/2006
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Last Update Date | 06/18/2008
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Provider Practice Location Address
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Address Line | 1947 CABLE ST
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City | SAN DIEGO
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State | CA
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Zip | 92107-2807
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Country | US
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Telephone | 619-223-7164
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Fax | 619-223-5443
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Provider Business Mailing Address
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Address Line | 1947 CABLE ST
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City | SAN DIEGO
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State | CA
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Zip | 92107-2807
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Country | US
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Telephone | 619-223-7164
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Fax | 619-223-5443
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Authorized Official
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Title or Position | OWNER
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Name | DR. JEOFFRY BRUCE GORDON
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Credential | MD
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Telephone | 619-223-7164
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | G19279
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License Number State | CA
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