=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518945500
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DOUGLAS A JORDAN JR. D.P.M.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/09/2006
-----------------------------------------------------
Last Update Date | 11/30/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11528 US HIGHWAY 19
-----------------------------------------------------
City | PORT RICHEY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34668-1442
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-868-2151
-----------------------------------------------------
Fax | 727-868-7379
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11528 US HIGHWAY 19
-----------------------------------------------------
City | PORT RICHEY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34668-1442
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-868-2151
-----------------------------------------------------
Fax | 727-819-8362
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number | PO 2114
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | PO 2114
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------