Provider Demographics
NPI:1518374784
Name:TEITELBAUM, JORDAN (DO)
Entity Type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:
Last Name:TEITELBAUM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8780 W GOLF RD STE 200
Mailing Address - Street 2:
Mailing Address - City:NILES
Mailing Address - State:IL
Mailing Address - Zip Code:60714-5611
Mailing Address - Country:US
Mailing Address - Phone:847-674-5585
Mailing Address - Fax:847-824-1698
Practice Address - Street 1:8780 W GOLF RD STE 200
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:IL
Practice Address - Zip Code:60714-5611
Practice Address - Country:US
Practice Address - Phone:847-674-5585
Practice Address - Fax:847-824-1698
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-18
Last Update Date:2021-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL036.152684207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program