MEDICARE: DR. SUSANNA REBA GORDON M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0001X	Radiation Oncology Physician	49114	CO
2	2085R0001X	Radiation Oncology Physician	34232	IA
3	2085R0001X	Radiation Oncology Physician	G84560	CA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	CB216780	OTHER	CA	MEDICARE PTAN
2	CA142866	OTHER	CA	MEDICARE PTAN
3	CA153446	OTHER	CA	MEDICARE PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1952309056
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SUSANNA REBA GORDON M.D.

Provider Business Mailing Address
First Line	:	PO BOX 512185
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90051-0185
Country	:	US
Telephone Number	:	626-775-3514
Fax Number	:

Provider Business Practice Location Address
First Line	:	6939 PALM CT
Second Line	:
City	:	RIVERSIDE
State	:	CA
Zip	:	92506-2815
Country	:	US
Telephone Number	:	951-683-6771
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/12/2005
Last Update Date	:	12/15/2020

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