Healthcare Provider Details

I. General information

NPI: 1205510989
Provider Name (Legal Business Name): JORDAN ANTHONY LEBRON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2023
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1702 UNIVERSITY DR S
FARGO ND
58103-4940
US

IV. Provider business mailing address

400 E 3RD ST
DULUTH MN
55805-1951
US

V. Phone/Fax

Practice location:
  • Phone: 218-786-8364
  • Fax:
Mailing address:
  • Phone: 218-786-8364
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number24193
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: