Provider Demographics
NPI:1902830359
Name:LUM, GORDON S (MD)
Entity Type:Individual
Prefix:DR
First Name:GORDON
Middle Name:S
Last Name:LUM
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 1:4605 NANTUCKET DR
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96001-5844
Mailing Address - Country:US
Mailing Address - Phone:530-945-0906
Mailing Address - Fax:530-776-5636
Practice Address - Street 1:4605 NANTUCKET DR
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-5844
Practice Address - Country:US
Practice Address - Phone:530-945-0906
Practice Address - Fax:530-776-5636
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2022-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG55623207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G556230Medicaid
CABO902YMedicare PIN
CA00G556230Medicare PIN
CA00G556230Medicaid