Healthcare Provider Details

I. General information

NPI: 1992067060
Provider Name (Legal Business Name): JORDAN MILLS D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2012
Last Update Date: 11/29/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2902 HARVEY ST
MADISON WI
53705-3504
US

IV. Provider business mailing address

2902 HARVEY ST
MADISON WI
53705-3504
US

V. Phone/Fax

Practice location:
  • Phone: 714-869-4555
  • Fax:
Mailing address:
  • Phone: 714-869-4555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number64173-21
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number64173-21
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: