MEDICARE: DEBRA ELAINE JORDAN D.O.

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	207V00000X	Obstetrics & Gynecology Physician	032592	GA

General Provider Information

NPI Number	:	1629153689
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEBRA ELAINE JORDAN D.O.

Provider Business Mailing Address
First Line	:	235 RYAN RD
Second Line	:
City	:	WINDER
State	:	GA
Zip	:	30680-3564
Country	:	US
Telephone Number	:	770-867-8007
Fax Number	:	770-586-5489

Provider Business Practice Location Address
First Line	:	2739 FELTON DR
Second Line	:
City	:	EAST POINT
State	:	GA
Zip	:	30344-3603
Country	:	US
Telephone Number	:	404-766-8371
Fax Number	:

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

Provider Enumeration Date	:	10/26/2006
Last Update Date	:	07/08/2007

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