Healthcare Provider Details

I. General information

NPI: 1043891575
Provider Name (Legal Business Name): JAROM JARDINE DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2021
Last Update Date: 07/26/2024
Certification Date: 07/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2050A 2ND ST SE
KIRTLAND AFB NM
87117-1873
US

IV. Provider business mailing address

4881 SUGAR MAPLE DR
DAYTON OH
45433-5529
US

V. Phone/Fax

Practice location:
  • Phone: 505-846-3200
  • Fax:
Mailing address:
  • Phone: 937-522-4784
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number34.016257
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: