Provider Demographics
NPI:1962513291
Name:GORDON, JODY (MD)
Entity type:Individual
Prefix:
First Name:JODY
Middle Name:
Last Name:GORDON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:10470 OLD PLACERVILLE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95827-2539
Mailing Address - Country:US
Mailing Address - Phone:855-771-0335
Mailing Address - Fax:
Practice Address - Street 1:1020 29TH ST
Practice Address - Street 2:SUITE 140
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-5125
Practice Address - Country:US
Practice Address - Phone:916-733-5044
Practice Address - Fax:916-733-8240
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2015-07-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG57777207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G577770Medicaid
A53333Medicare UPIN
CA00G577770Medicaid