Provider Demographics
NPI:1154511442
Name:JORDAN M USUNOV M D A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:JORDAN M USUNOV M D A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:JORDAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:USUNOV
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-836-2223
Mailing Address - Street 1:1540 N TRACY BLVD
Mailing Address - Street 2:A
Mailing Address - City:TRACY
Mailing Address - State:CA
Mailing Address - Zip Code:95376-2530
Mailing Address - Country:US
Mailing Address - Phone:209-836-2223
Mailing Address - Fax:209-836-2530
Practice Address - Street 1:1540 N TRACY BLVD
Practice Address - Street 2:A
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95376-2530
Practice Address - Country:US
Practice Address - Phone:209-836-2223
Practice Address - Fax:209-836-2530
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-01
Last Update Date:2013-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0806900002Medicare NSC