Provider Demographics
NPI:1902238579
Name:GORDON, RYAN JAMES (SFIDC)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:JAMES
Last Name:GORDON
Suffix:
Gender:M
Credentials:SFIDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9955 POMERADO RD BLDG 20300
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92131-2041
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9955 POMERADO RD BLDG 20300
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92131-2041
Practice Address - Country:US
Practice Address - Phone:858-537-8334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-06
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman