=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396891057
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JORDAN JOHN MICHELENA MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/26/2007
-----------------------------------------------------
Last Update Date | 08/19/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4477 WHITTIER BLVD
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90022-1535
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-264-2890
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4477 WHITTIER BLVD
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90022-1535
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-264-2890
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | A101937
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------