Provider Demographics
NPI:1578735460
Name:DR RYAN JORGENSON DPM LLC
Entity Type:Organization
Organization Name:DR RYAN JORGENSON DPM LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:JORGENSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:317-839-0959
Mailing Address - Street 1:5689 YORKTOWN TRCE
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46168-7428
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5689 YORKTOWN TRCE
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:IN
Practice Address - Zip Code:46168-7428
Practice Address - Country:US
Practice Address - Phone:317-839-0959
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-31
Last Update Date:2008-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN07001010A213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN859800Medicare PIN
V01208Medicare UPIN