Provider Demographics
NPI:1477711760
Name:LOFTIS, JORDAN L (MD)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:L
Last Name:LOFTIS
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 1:2400 N COURTENAY PKWY STE 100
Mailing Address - Street 2:
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32953-4127
Mailing Address - Country:US
Mailing Address - Phone:321-985-9097
Mailing Address - Fax:321-301-4869
Practice Address - Street 1:2400 N COURTENAY PKWY STE 100
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32953-4127
Practice Address - Country:US
Practice Address - Phone:321-985-9097
Practice Address - Fax:321-301-4869
Is Sole Proprietor?:No
Enumeration Date:2008-05-23
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO48796207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1477711760OtherNPI
TXP00712717Medicare PIN
TX197665602Medicaid
TX8BN843OtherBCBS