Provider Demographics
NPI:1386633378
Name:JORDAN, DAVID W (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:W
Last Name:JORDAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 MEDICAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:HELENA
Mailing Address - State:MT
Mailing Address - Zip Code:59601-8022
Mailing Address - Country:US
Mailing Address - Phone:406-443-3457
Mailing Address - Fax:406-443-7201
Practice Address - Street 1:1 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:HELENA
Practice Address - State:MT
Practice Address - Zip Code:59601-8022
Practice Address - Country:US
Practice Address - Phone:406-443-3457
Practice Address - Fax:406-443-7201
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-21
Last Update Date:2009-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT4325207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00089863OtherPALMETTO GBA
MT0000012340OtherBLUE CROSS BLUE SHIELD
MT055094Medicaid
MT9989778OtherMEDICAID PASSPORT
MT0000012340OtherBLUE CROSS BLUE SHIELD
MT055094Medicaid