Provider Demographics
NPI:1073583035
Name:ROSS, JORDAN S (DO)
Entity Type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:S
Last Name:ROSS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2730 S VAL VISTA DR
Mailing Address - Street 2:SUITE 138, BLDG. 7
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85296-6675
Mailing Address - Country:US
Mailing Address - Phone:480-686-9686
Mailing Address - Fax:480-686-9508
Practice Address - Street 1:2730 S VAL VISTA DR
Practice Address - Street 2:SUITE 138, BLDG. 7
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85296-6675
Practice Address - Country:US
Practice Address - Phone:480-686-9686
Practice Address - Fax:480-686-9508
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-24
Last Update Date:2012-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3119207Q00000X, 204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ3119OtherSTATE LICENSE
ZWMBQLMedicare ID - Type Unspecified
AZ3119OtherSTATE LICENSE