Provider Demographics
NPI:1306920822
Name:GORDON, JEAN (MD,PHD)
Entity type:Individual
Prefix:DR
First Name:JEAN
Middle Name:
Last Name:GORDON
Suffix:
Gender:F
Credentials:MD,PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2660 SOLACE PL
Mailing Address - Street 2:SUITE C
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:CA
Mailing Address - Zip Code:94040-4316
Mailing Address - Country:US
Mailing Address - Phone:650-938-6559
Mailing Address - Fax:650-938-6510
Practice Address - Street 1:2660 SOLACE PL
Practice Address - Street 2:SUITE C
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:CA
Practice Address - Zip Code:94040-4316
Practice Address - Country:US
Practice Address - Phone:650-938-6559
Practice Address - Fax:650-938-6510
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG60973174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF15483Medicare UPIN
CA00G609730Medicare ID - Type UnspecifiedPROVIDER NUMBER