Healthcare Provider Details

I. General information

NPI: 1821614645
Provider Name (Legal Business Name): JORDAN SPUSTA DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2020
Last Update Date: 08/21/2024
Certification Date: 08/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1474 TANYARD ROAD SUITE A100
SEWELL NJ
08080
US

IV. Provider business mailing address

1474 TANYARD ROAD SUITE A100
SEWELL NJ
08080
US

V. Phone/Fax

Practice location:
  • Phone: 856-566-7010
  • Fax: 856-566-6961
Mailing address:
  • Phone: 856-566-7010
  • Fax: 856-566-6961

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number25MB11948700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: