Provider Demographics
NPI:1518945500
Name:JORDAN, DOUGLAS A JR (DPM)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:A
Last Name:JORDAN
Suffix:JR
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 1:11528 US HIGHWAY 19
Mailing Address - Street 2:
Mailing Address - City:PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34668-1442
Mailing Address - Country:US
Mailing Address - Phone:727-868-2151
Mailing Address - Fax:727-819-8362
Practice Address - Street 1:11528 US HIGHWAY 19
Practice Address - Street 2:
Practice Address - City:PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34668-1442
Practice Address - Country:US
Practice Address - Phone:727-868-2151
Practice Address - Fax:727-868-7379
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2009-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO 2114213E00000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL102751OtherAVMED
FL10593101OtherCITRUS GCMCI
FL480018908OtherRAILROAD MEDICARE
FL65211OtherBLUE CROSS BLUE SHIELD FLORIDA
FL985373OtherUNITED HEALTH CARE
FL01352OtherUNIVERSAL HEALTH CARE
FL10593102OtherCITRUS GCMCII
FL057053200Medicaid
FL6200309OtherGHI
FL985373OtherUNITED HEALTH CARE
FL480018908OtherRAILROAD MEDICARE