Provider Demographics
NPI:1952309056
Name:GORDON, SUSANNA REBA (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSANNA
Middle Name:REBA
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:PO BOX 512185
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90051-0185
Mailing Address - Country:US
Mailing Address - Phone:626-775-3514
Mailing Address - Fax:
Practice Address - Street 1:6939 PALM CT
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-2815
Practice Address - Country:US
Practice Address - Phone:951-683-6771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO491142085R0001X
IA342322085R0001X
CAG845602085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB216780OtherMEDICARE PTAN
CACA142866OtherMEDICARE PTAN
CACA153446OtherMEDICARE PTAN
IA1246710Medicaid
IA1246710Medicaid
COCOA104659Medicare PIN
IAH48443Medicare UPIN