Healthcare Provider Details

I. General information

NPI: 1265957906
Provider Name (Legal Business Name): DANIEL JORGENSEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2017
Last Update Date: 08/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 GREAT VALLEY PKWY STE 160
MALVERN PA
19355-1445
US

IV. Provider business mailing address

PO BOX 418
WAYNE PA
19087-0418
US

V. Phone/Fax

Practice location:
  • Phone: 484-328-4702
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0208X
TaxonomyPediatric Infectious Diseases Physician
License Number181323-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: