MEDICARE: JORDAN RAY ILSE MD

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	207N00000X	Dermatology Physician	N8307	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	N8307	OTHER	TX	TX LICENSE

General Provider Information

NPI Number	:	1477712479
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JORDAN RAY ILSE MD

Provider Business Mailing Address
First Line	:	1300 EAST 6TH AVE
Second Line	:
City	:	BELTON
State	:	TX
Zip	:	76513
Country	:	US
Telephone Number	:	254-778-5400
Fax Number	:	254-778-5444

Provider Business Practice Location Address
First Line	:	1300 E. 6TH AVENUE
Second Line	:
City	:	BELTON
State	:	TX
Zip	:	76513-2810
Country	:	US
Telephone Number	:	254-778-5400
Fax Number	:	254-778-5444

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

Provider Enumeration Date	:	06/04/2008
Last Update Date	:	08/04/2017

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