Provider Demographics
NPI:1619061892
Name:REUBEN, GORDON PHILIP (MD)
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:PHILIP
Last Name:REUBEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2220 LYNN ROAD
Mailing Address - Street 2:#204
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91360-8008
Mailing Address - Country:US
Mailing Address - Phone:805-497-2201
Mailing Address - Fax:805-497-6602
Practice Address - Street 1:2220 LYNN ROAD
Practice Address - Street 2:#204
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360-8008
Practice Address - Country:US
Practice Address - Phone:805-497-2201
Practice Address - Fax:805-497-6602
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2010-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG40123207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G401230Medicaid
G40123Medicare ID - Type Unspecified
CA00G401230Medicaid