Healthcare Provider Details

I. General information

NPI: 1609939099
Provider Name (Legal Business Name): JORDAN M USUNOV MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2006
Last Update Date: 01/31/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1540 N TRACY BLVD A
TRACY CA
95376-2903
US

IV. Provider business mailing address

1540 N TRACY BLVD A
TRACY CA
95376-2903
US

V. Phone/Fax

Practice location:
  • Phone: 209-836-2223
  • Fax: 209-836-2530
Mailing address:
  • Phone: 209-836-2223
  • Fax: 209-836-2530

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberC38780
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: