Healthcare Provider Details

I. General information

NPI: 1861734915
Provider Name (Legal Business Name): JORDAN TAYLOR VULCANO DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2013
Last Update Date: 07/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 S. CRISMON ROAD SUITE 191
MESA AZ
85209
US

IV. Provider business mailing address

1801 S. CRISMON ROAD SUITE 191
MESA AZ
85209
US

V. Phone/Fax

Practice location:
  • Phone: 480-621-5891
  • Fax: 480-704-4019
Mailing address:
  • Phone: 480-621-5891
  • Fax: 480-704-4019

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberD01358731
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number007950
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: