Provider Demographics
NPI:1598844524
Name:JORDAN, ROBERT R (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:R
Last Name:JORDAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3400 LOMA VISTA RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-3033
Mailing Address - Country:US
Mailing Address - Phone:805-644-9321
Mailing Address - Fax:805-644-9320
Practice Address - Street 1:3400 LOMA VISTA RD
Practice Address - Street 2:SUITE 1
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-3033
Practice Address - Country:US
Practice Address - Phone:805-644-9321
Practice Address - Fax:805-644-9320
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2010-12-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG57518207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G575181Medicaid
CAE02813Medicare UPIN
CA00G575181Medicaid