Healthcare Provider Details

I. General information

NPI: 1578735460
Provider Name (Legal Business Name): DR RYAN JORGENSON DPM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/31/2008
Last Update Date: 03/31/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5689 YORKTOWN TRCE
PLAINFIELD IN
46168-7428
US

IV. Provider business mailing address

5689 YORKTOWN TRCE
PLAINFIELD IN
46168-7428
US

V. Phone/Fax

Practice location:
  • Phone: 317-839-0959
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number07001010A
License Number StateIN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. RYAN JAMES JORGENSON
Title or Position: PODIATRIST
Credential: DPM
Phone: 317-839-0959