Provider Demographics
NPI:1043205016
Name:ZUCKERMAN, JORDAN SPENCE (MD)
Entity Type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:SPENCE
Last Name:ZUCKERMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2383 BELL BLVD
Mailing Address - Street 2:UPPER LEVEL
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11360-2053
Mailing Address - Country:US
Mailing Address - Phone:718-423-0200
Mailing Address - Fax:718-423-3134
Practice Address - Street 1:2383 BELL BLVD
Practice Address - Street 2:UPPER LEVEL
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11360-2053
Practice Address - Country:US
Practice Address - Phone:718-423-0200
Practice Address - Fax:718-423-3134
Is Sole Proprietor?:No
Enumeration Date:2005-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY168660207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
E82863Medicare UPIN
01032GMedicare ID - Type Unspecified