Provider Demographics
NPI:1114360930
Name:HEATH, JORDAN LUPO (MD)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:LUPO
Last Name:HEATH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JORDAN
Other - Middle Name:ELIZABETH
Other - Last Name:LUPO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4881 NW 8TH AVE.
Mailing Address - Street 2:SUITE 2
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32605-4582
Mailing Address - Country:US
Mailing Address - Phone:352-416-1082
Mailing Address - Fax:352-373-6144
Practice Address - Street 1:4343 NEWBERRY RD STE 1
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32607-2822
Practice Address - Country:US
Practice Address - Phone:352-331-3502
Practice Address - Fax:352-331-3488
Is Sole Proprietor?:No
Enumeration Date:2013-04-10
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME149410207KA0200X, 207KA0200X
MO2016018713208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL111133800Medicaid