Provider Demographics
NPI:1477712479
Name:ILSE, JORDAN RAY (MD)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:RAY
Last Name:ILSE
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 1:1300 EAST 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:BELTON
Mailing Address - State:TX
Mailing Address - Zip Code:76513
Mailing Address - Country:US
Mailing Address - Phone:254-778-5400
Mailing Address - Fax:254-778-5444
Practice Address - Street 1:1300 E. 6TH AVENUE
Practice Address - Street 2:
Practice Address - City:BELTON
Practice Address - State:TX
Practice Address - Zip Code:76513-2810
Practice Address - Country:US
Practice Address - Phone:254-778-5400
Practice Address - Fax:254-778-5444
Is Sole Proprietor?:No
Enumeration Date:2008-06-04
Last Update Date:2017-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN8307207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXN8307OtherTX LICENSE