MEDICARE: JORDAN ENID HOLLSTEN M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207WX0200X	Ophthalmic Plastic and Reconstructive Surgery Physician	P5535	TX
2	207W00000X	Ophthalmology Physician	P5535	TX

General Provider Information

NPI Number	:	1316270069
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JORDAN ENID HOLLSTEN M.D.

Provider Business Mailing Address
First Line	:	4114 POND HILL RD STE 100
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78231-1273
Country	:	US
Telephone Number	:	210-616-0739
Fax Number	:	210-616-0972

Provider Business Practice Location Address
First Line	:	4114 POND HILL RD STE 100
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78231-1273
Country	:	US
Telephone Number	:	210-616-0739
Fax Number	:	210-616-0972

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/14/2009
Last Update Date	:	01/06/2020

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