Provider Demographics
NPI:1144212549
Name:JORDAN, ANTHONY SCOTT (MD)
Entity Type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:SCOTT
Last Name:JORDAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712
Mailing Address - Country:US
Mailing Address - Phone:208-375-4955
Mailing Address - Fax:208-375-5568
Practice Address - Street 1:12080 MCMILLAN RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-2462
Practice Address - Country:US
Practice Address - Phone:208-375-4955
Practice Address - Fax:208-375-5568
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01056364A207Q00000X
IDM-9584207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID20000376Medicare PIN