Healthcare Provider Details

I. General information

NPI: 1649264441
Provider Name (Legal Business Name): MILAN JORDAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2005
Last Update Date: 11/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 WESTERN AVE
MANITOWOC WI
54220-3712
US

IV. Provider business mailing address

PO BOX 2290
MANITOWOC WI
54221-2290
US

V. Phone/Fax

Practice location:
  • Phone: 920-320-3165
  • Fax: 930-320-3169
Mailing address:
  • Phone: 920-320-2591
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number32315
License Number StateWI

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier34516300
Identifier TypeMEDICAID
Identifier StateWI
Identifier Issuer
# 2
Identifier208600000X
Identifier TypeMEDICAID
Identifier StateWI
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: