Provider Demographics
NPI:1205221017
Name:WOMACK, JORDAN (DPM)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:WOMACK
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6405 S 3000 E STE 300
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84121-6977
Mailing Address - Country:US
Mailing Address - Phone:801-266-3113
Mailing Address - Fax:801-266-5633
Practice Address - Street 1:270 E 8TH AVE
Practice Address - Street 2:SUITE N102
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-5708
Practice Address - Country:US
Practice Address - Phone:970-903-9853
Practice Address - Fax:970-616-6745
Is Sole Proprietor?:No
Enumeration Date:2015-03-30
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPOD.468213ES0103X
MI5901002564213ES0103X
COPOD.0000908213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery