Provider Demographics
NPI:1891767604
Name:GORDON, SUSAN GRACE (OD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:GRACE
Last Name:GORDON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 E CALAVERAS BLVD
Mailing Address - Street 2:
Mailing Address - City:MILPITAS
Mailing Address - State:CA
Mailing Address - Zip Code:95035-5543
Mailing Address - Country:US
Mailing Address - Phone:408-263-2040
Mailing Address - Fax:
Practice Address - Street 1:1301 E CALAVERAS BLVD
Practice Address - Street 2:
Practice Address - City:MILPITAS
Practice Address - State:CA
Practice Address - Zip Code:95035-5543
Practice Address - Country:US
Practice Address - Phone:408-263-2040
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7200T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist