Provider Demographics
NPI:1023190717
Name:CORDOVA, JOSE (DC)
Entity Type:Individual
Prefix:MR
First Name:JOSE
Middle Name:
Last Name:CORDOVA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8000 CALUMET AVE
Mailing Address - Street 2:
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-1227
Mailing Address - Country:US
Mailing Address - Phone:219-836-2580
Mailing Address - Fax:219-836-9366
Practice Address - Street 1:8000 CALUMET AVE
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-1227
Practice Address - Country:US
Practice Address - Phone:219-836-2580
Practice Address - Fax:219-836-9366
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08001591A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000092523OtherANTHEM
IL90000866OtherBCBS IL
IN000000092523OtherANTHEM
IL90000866OtherBCBS IL