Healthcare Provider Details

I. General information

NPI: 1972580314
Provider Name (Legal Business Name): NATHAN H JORGENSEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2005
Last Update Date: 03/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

789 CENTRAL AVE
DOVER NH
03820-2526
US

IV. Provider business mailing address

3998 FAIR RIDGE DR STE 300
FAIRFAX VA
22033-2921
US

V. Phone/Fax

Practice location:
  • Phone: 603-749-7246
  • Fax: 603-749-2453
Mailing address:
  • Phone: 703-295-9360
  • Fax: 703-766-9725

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number9363
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: