Provider Demographics
NPI:1114117603
Name:GORDON, MONICA TERESA PETERSON (MD)
Entity Type:Individual
Prefix:
First Name:MONICA TERESA
Middle Name:PETERSON
Last Name:GORDON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1370 S STATE ST STE B
Mailing Address - Street 2:
Mailing Address - City:SAN JACINTO
Mailing Address - State:CA
Mailing Address - Zip Code:92583-4922
Mailing Address - Country:US
Mailing Address - Phone:951-791-3596
Mailing Address - Fax:951-791-3397
Practice Address - Street 1:1370 S STATE ST STE B
Practice Address - Street 2:
Practice Address - City:SAN JACINTO
Practice Address - State:CA
Practice Address - Zip Code:92583-4922
Practice Address - Country:US
Practice Address - Phone:951-791-3596
Practice Address - Fax:951-791-3397
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-31
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA860892084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry