NPIMap

Individual provider Active NPI

Jacob Samuel Gordner, MD

  • Student in an Organized Health Care Education/Training Program
  • Stanford, CA
National Provider Identifier
1124762026
Registry record updated Apr 26, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Student in an Organized Health Care Education/Training ProgramTaxonomy code 390200000X
License
A175900 Issued in CA
Practice address
300 Pasteur Dr
Stanford, CA 94305-2296
Phone
(650) 725-1812
NPI assigned
Apr 26, 2022
Sex
Male
Sole proprietor
Yes

NPPES NPI Registry

Updated by the provider on Apr 26, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Student in an Organized Health Care Education/Training Program 390200000X A175900 CA Primary

Addresses

Primary practice location

300 Pasteur Dr
Stanford, CA 94305-2296

Mailing address

103-182 Princess St
Kingston, ON K7L 1B1
CA

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in PA, NV2 enrollments
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
I20231214003333 PA Practitioner - Diagnostic Radiology 9931558046 Reassigns benefits to 3 organizations
I20260508000090 NV Practitioner - Diagnostic Radiology 9931558046 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Diagnostic Radiology
Education
Queen'S School of Medicine, 2017
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Shelin Agrawal and Hyer PLLCGroup PAC ID 5890955959, 65 clinicians
Ellis Bandt Birkin Kollins and Wong PLLCGroup PAC ID 4486568946, 68 clinicians

Practice addresses (Care Compare)

1111 Locust St
Unit 2I
Philadelphia, PA 19107-5869
Phone (702) 759-8600

325 Penn Rd
Unit 564
Wynnewood, PA 19096-1465
Phone (702) 759-8600

6000 Red Tail LN
Gibsonia, PA 15044-6046
Phone (702) 759-8600

Hospital & facility affiliations

  • Summerlin Hospital Medical Center Hospital, Las Vegas, NV, CCN 290041
  • Centennial Hills Hospital Medical Center Hospital, Las Vegas, NV, CCN 290054
  • Spring Valley Hospital Medical Center Hospital, Las Vegas, NV, CCN 290046

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

State licenses

LicenseStateTypeSpecialty
A175900CAMDStudent in an Organized Health Care Education/Training Program

Practice roles

OrganizationSpecialtyStatusNew patients
Medical Imaging Associates of Idaho Falls, Inc CurrentSince Jan 1, 2026 Accepting new patients
Shelin Agrawal and Hyer PLLC CurrentSince Dec 7, 2023 Accepting new patients
Ellis Bandt Birkin Kollins & Wong PLLC CurrentSince Dec 7, 2023 Accepting new patients

Locations

620 Shadow Ln
Las Vegas, NV 89106
Phone (702) 388-4506

2020 Palomino Ln
Ste 100
Las Vegas, NV 89106
Phone (702) 759-8779

5400 S Rainbow Blvd
Las Vegas, NV 89118
Phone (702) 252-7342

6900 N Durango Dr
Las Vegas, NV 89149
Phone (702) 380-1964

360 S Lola Ln
Pahrump, NV 89048
Phone (775) 751-7500

Organizations & group practices 4

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Hospital & facility affiliations 8

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1650931200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1650931200000",
    "number": "1124762026",
    "addresses": [
        {
            "country_code": "CA",
            "country_name": "Canada",
            "address_purpose": "MAILING",
            "address_type": "FGN",
            "address_1": "103-182 PRINCESS ST",
            "city": "KINGSTON",
            "state": "ON",
            "postal_code": "K7L 1B1"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "300 PASTEUR DR",
            "city": "STANFORD",
            "state": "CA",
            "postal_code": "943052296",
            "telephone_number": "650-725-1812"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "GORDNER",
        "first_name": "JACOB",
        "middle_name": "SAMUEL",
        "name_prefix": "Dr.",
        "credential": "MD",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2022-04-26",
        "last_updated": "2022-04-26",
        "certification_date": "2022-04-26",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "390200000X",
            "taxonomy_group": "",
            "desc": "Student in an Organized Health Care Education/Training Program",
            "state": "CA",
            "license": "A175900",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Stanford, CA

Sources for this page

Verify at the official NPI Registry.