=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194354217
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JORDAN MICHAEL MAXWELL DO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/02/2020
-----------------------------------------------------
Last Update Date | 06/18/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9849 KENWORTHY ST
-----------------------------------------------------
City | EL PASO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79924-4402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 915-215-5500
-----------------------------------------------------
Fax | 915-215-8655
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5130 GATEWAY BLVD EAST C.P. MSC51015
-----------------------------------------------------
City | EL PASO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79905
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 915-215-4480
-----------------------------------------------------
Fax | 915-215-5386
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207QS0010X
-----------------------------------------------------
Taxonomy Name | Sports Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number | V1186
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | BP10085708
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | V1186
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------