Provider Demographics
NPI:1033441019
Name:PERRY, JORDAN (MD)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:PERRY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:987 R C HOAG DR
Mailing Address - Street 2:
Mailing Address - City:SALAMANCA
Mailing Address - State:NY
Mailing Address - Zip Code:14779-1365
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:987 R C HOAG DR
Practice Address - Street 2:
Practice Address - City:SALAMANCA
Practice Address - State:NY
Practice Address - Zip Code:14779-1365
Practice Address - Country:US
Practice Address - Phone:716-945-5894
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-02
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI63012207Q00000X, 207Q00000X
NY263118207Q00000X
OH57.014152207Q00000X
TXR6257207Q00000X, 261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY463483745Medicaid