Healthcare Provider Details

I. General information

NPI: 1588634794
Provider Name (Legal Business Name): DANIEL L JORGENSEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2006
Last Update Date: 07/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 GRAND AVE
SPENCER IA
51301-3641
US

IV. Provider business mailing address

PO BOX 1194
SPENCER IA
51301-1194
US

V. Phone/Fax

Practice location:
  • Phone: 712-262-8120
  • Fax: 712-262-7028
Mailing address:
  • Phone: 712-262-8120
  • Fax: 712-262-7028

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number21909
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: