Healthcare Provider Details

I. General information

NPI: 1205221017
Provider Name (Legal Business Name): JORDAN WOMACK DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2015
Last Update Date: 02/05/2024
Certification Date: 02/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

270 E 8TH AVE SUITE N102
DURANGO CO
81301-5708
US

IV. Provider business mailing address

6405 S 3000 E STE 300
SALT LAKE CITY UT
84121-6977
US

V. Phone/Fax

Practice location:
  • Phone: 970-903-9853
  • Fax: 970-616-6745
Mailing address:
  • Phone: 801-266-3113
  • Fax: 801-266-5633

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPOD.468
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number5901002564
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPOD.0000908
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: