Kenyetta Michelle Gordon, MD
Individual provider Active NPI Family Medicine Physician · Crescent City, CA
NPI 1013101161 · NPPES record last updated May 26, 2023
Key facts
- NPI
- 1013101161
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Family Medicine Physician 207Q00000X
- License
- C186176 (CA)
- Practice address
- 1675 Northcrest Dr
Crescent City, CA 95531-8928 - Phone
- (707) 464-2750
- NPI assigned
- Aug 31, 2007
- Sex
- Female
- Sole proprietor
- No
Organizations & group practices 39
Hospital & facility affiliations 8
Medicare Care Compare profile
- Specialty
- Family Practice
- Education
- Other, 2006
- Medicare assignment
- Accepts the Medicare-approved amount as payment in full
- Group practices
- United Indian Health Services, Inc.
Open Door Community Health Centers
Practice addresses (Care Compare)
1675 Northcrest Dr
Crescent City, CA 95531-8928
Phone (707) 464-2750
2200 Tydd St
Eureka, CA 95501-1284
Phone (707) 441-1624
550 E Washington Blvd
Crescent City, CA 95531-8160
Phone (707) 465-6925
Hospital & facility affiliations
- Sutter Coast Home Care
- Sutter Coast Hospital
- Curry General Hospital
- Providence St Joseph Hospital
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (3 enrollments) in AR, TX, CA
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: Yes · Hospice: Yes
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20101026000025 | AR | Practitioner - Family Practice |
3870786676 | Reassigns benefits to 4 organizations |
| I20200416001338 | TX | Practitioner - Family Practice | 3870786676 | Reassigns benefits to 1 organization |
| I20220928000794 | CA | Practitioner - Family Practice | 3870786676 | Reassigns benefits to 1 organization |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| E-6423 | AR | MD | Family Medicine Physician |
| C186176 | CA | MD | Family Medicine Physician |
Practice roles
Locations
815 Fort St
Ste A
Barling, AR 72923
Phone (479) 494-5740
3000 Medical Center Pkwy
Bentonville, AR 72712
Phone (479) 553-2524
4253 N Crossover Rd
Fayetteville, AR 72703
Phone (479) 443-6496
201 N Clifton St
Fordyce, AR 71742
Phone (870) 352-6300
609 W Maple Ave
Springdale, AR 72764
Phone (479) 751-5711
1275 8th St
Arcata, CA 95521
1600 Weeot Way
Arcata, CA 95521
Phone (707) 825-5000
550 E Washington Blvd
Crescent City, CA 95531
Phone (707) 465-4636
550 E Washington Blvd
Ste 100
Crescent City, CA 95531
Phone (707) 465-6925
1675 Northcrest Dr
Crescent City, CA 95531
Phone (707) 464-2750
1081 N China Lake Blvd
Ridgecrest, CA 93555
Phone (760) 446-0616
105 E Sydnor Ave
Ste 100
Ridgecrest, CA 93555
Phone (760) 446-6404
501 N Indian Rd
Smith River, CA 95567
Phone (707) 487-0215
53585 Nokomis Rd
Ashland, WI 54806
Phone (715) 682-7133
Interoperability endpoints
- kgordon720208@direct.ochin.org
- kgordon743440@direct.ochin.org
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician | 207Q00000X | 19863 | NV | |
| Family Medicine Physician | 207Q00000X | E-6423 | AR | |
| Family Medicine Physician | 207Q00000X | C186176 | CA | Yes |
Addresses
Primary practice location
1675 Northcrest Dr
Crescent City, CA 95531-8928
Mailing address
1600 Weeot Way
Arcata, CA 95521-4734
Other practice location 1
501 N Indian Rd
Smith River, CA 95567-9509
Phone (707) 487-0215
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1013101161 | Medicaid | NV |
Other providers in Crescent City, CA
- Stacey Anne Glass
- Margaret Helen Godwyn
- Dulce Rafaela Gomez
- Maria Raquel Gonzales-Flores
- David Gonzales
- Vicki R Gordon
- John Michael Goss
- Gray Chiropractic PC
- Sean Gray
- Holly Greene
All providers in Crescent City, CA · Family Medicine Physician in California
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on May 26, 2023. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.