Provider Demographics
NPI:1598949828
Name:JORDAN & PRIETO PA
Entity Type:Organization
Organization Name:JORDAN & PRIETO PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:OCTAVIO
Authorized Official - Middle Name:ENRIQUE
Authorized Official - Last Name:PRIETO
Authorized Official - Suffix:
Authorized Official - Credentials:MD,
Authorized Official - Phone:954-583-0778
Mailing Address - Street 1:4302 W BROWARD BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33317-3700
Mailing Address - Country:US
Mailing Address - Phone:954-583-0778
Mailing Address - Fax:954-583-8140
Practice Address - Street 1:4302 W BROWARD BLVD STE 200
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33317-3700
Practice Address - Country:US
Practice Address - Phone:954-583-0778
Practice Address - Fax:954-583-8140
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-21
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME34072207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL39312BMedicare PIN