Provider Demographics
NPI:1962483099
Name:GORDON, JOHN B (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:B
Last Name:GORDON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JOHN
Other - Middle Name:B
Other - Last Name:GORDON
Other - Suffix:III
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:3131 BERGER AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-4203
Mailing Address - Country:US
Mailing Address - Phone:858-244-6800
Mailing Address - Fax:858-244-6909
Practice Address - Street 1:3131 BERGER AVE STE 200
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-4203
Practice Address - Country:US
Practice Address - Phone:858-244-6865
Practice Address - Fax:858-244-6909
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC42631207RC0000X, 2085R0204X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C426310Medicaid
CAB76546Medicare UPIN
CAWC42631BMedicare PIN