Healthcare Provider Details

I. General information

NPI: 1275988313
Provider Name (Legal Business Name): JORDAN MALENKE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2016
Last Update Date: 07/29/2022
Certification Date: 10/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

92 CAMPUS DR FL 3
SCARBOROUGH ME
04074-7228
US

IV. Provider business mailing address

92 CAMPUS DR FL 3
SCARBOROUGH ME
04074-7228
US

V. Phone/Fax

Practice location:
  • Phone: 207-797-5753
  • Fax:
Mailing address:
  • Phone: 207-797-5753
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number88850
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberMD26065
License Number StateME
# 4
Primary TaxonomyN
Taxonomy Code207YX0602X
TaxonomyOtolaryngic Allergy Physician
License Number88850
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: