Healthcare Provider Details

I. General information

NPI: 1043710759
Provider Name (Legal Business Name): JORDAN BLUTH OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/19/2018
Last Update Date: 02/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1055 S STAPLEY DR
MESA AZ
85204-5013
US

IV. Provider business mailing address

309 E INGRAM ST
MESA AZ
85201-2355
US

V. Phone/Fax

Practice location:
  • Phone: 480-833-9100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2233
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: