MEDICARE: OCEAN BEACH MEDICAL GROUP

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	207Q00000X	Family Medicine Physician	G19279	CA

Other Identifiers

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

General Provider Information

NPI Number	:	1992710826
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OCEAN BEACH MEDICAL GROUP

Provider Business Mailing Address
First Line	:	1947 CABLE ST
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92107-2807
Country	:	US
Telephone Number	:	619-223-7164
Fax Number	:	619-223-5443

Provider Business Practice Location Address
First Line	:	1947 CABLE ST
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92107-2807
Country	:	US
Telephone Number	:	619-223-7164
Fax Number	:	619-223-5443

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JEOFFRY BRUCE GORDON
Credential	:	MD
Telephone Number	:	619-223-7164

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

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Practice Location Address:

1947 CABLE ST
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92107-2807

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1891882619 — DR. RODNEY MELLOR D.D.S.
Practice Location Address:

1943 CABLE ST
SAN DIEGO, CA
92107-2807

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1972641231 — MS. NANCY H. REIN MSN, FNP
Practice Location Address:

1933 CABLE ST
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1396950135 — KATHY SHADLE JAMES DNSC, NP
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