Healthcare Provider Details

I. General information

NPI: 1275107377
Provider Name (Legal Business Name): JORDAN SCOTT ANDERSON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2021
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 14TH AVE NW
ARDMORE OK
73401-1828
US

IV. Provider business mailing address

PO BOX 21228 DEPT 99
TULSA OK
74121-1228
US

V. Phone/Fax

Practice location:
  • Phone: 580-226-1251
  • Fax:
Mailing address:
  • Phone: 580-226-1251
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberV1011
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number9524
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: