Healthcare Provider Details

I. General information

NPI: 1316988900
Provider Name (Legal Business Name): ROBERT BRUCE JORDAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 07/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

253 WILDERNESS DR
BOYCE LA
71409-8618
US

IV. Provider business mailing address

PO BOX 7146
ALEXANDRIA LA
71306-0146
US

V. Phone/Fax

Practice location:
  • Phone: 318-443-2418
  • Fax: 318-443-2410
Mailing address:
  • Phone: 805-901-0204
  • Fax: 318-443-2410

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberC26156
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD.009180
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberJ1277
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: