Provider Demographics
NPI:1164428074
Name:JORDANIA, NINA T (MD)
Entity Type:Individual
Prefix:DR
First Name:NINA
Middle Name:T
Last Name:JORDANIA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:25111 PENNYROYAL DR
Mailing Address - Street 2:STE 1
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34134-7944
Mailing Address - Country:US
Mailing Address - Phone:630-740-8375
Mailing Address - Fax:630-740-8375
Practice Address - Street 1:6801 PORTO FINO CIR
Practice Address - Street 2:STE 1
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-4344
Practice Address - Country:US
Practice Address - Phone:239-225-0874
Practice Address - Fax:239-225-1465
Is Sole Proprietor?:No
Enumeration Date:2005-06-24
Last Update Date:2017-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361072342084P0800X
FLME1267502084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036107234OtherSTATE LICENSE
IL036107234Medicaid
IL1033149844OtherCDPG NPI
P00924097OtherMEDICARE RAILROAD (PROVIDER)
IL0222075OtherBLUE CROSS GROUP
CA4748OtherMEDICARE RAILROAD (GROUP)
IL036107234OtherSTATE LICENSE
IL036107234Medicaid
IL036107234OtherSTATE LICENSE