Basic Information
| Provider Information | |||||||||
| NPI: | 1952309056 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GORDON | ||||||||
| FirstName: | SUSANNA | ||||||||
| MiddleName: | REBA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 512185 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900510185 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6267753514 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6939 PALM CT | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925062815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9516836771 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2005 | ||||||||
| LastUpdateDate: | 12/15/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 12/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | 49114 | CO | N | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | 2085R0001X | 34232 | IA | N | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | 2085R0001X | G84560 | CA | Y | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | CB216780 | 01 | CA | MEDICARE PTAN | OTHER | CA142866 | 01 | CA | MEDICARE PTAN | OTHER | CA153446 | 01 | CA | MEDICARE PTAN | OTHER | 1246710 | 05 | IA | MEDICAID |