Healthcare Provider Details

I. General information

NPI: 1215966726
Provider Name (Legal Business Name): MARTIN I JORDANOV MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 09/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1161 21ST AVE S CCC-1121 MCN
NASHVILLE TN
37232-2675
US

IV. Provider business mailing address

1161 21ST AVE S CCC-1121 MCN
NASHVILLE TN
37232-2675
US

V. Phone/Fax

Practice location:
  • Phone: 615-322-3765
  • Fax: 615-322-3764
Mailing address:
  • Phone: 615-322-3765
  • Fax: 615-322-3764

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD39648
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: