Provider Demographics
NPI:1629493275
Name:JORDAN, MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:JORDAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 STONE GATE CT
Mailing Address - Street 2:
Mailing Address - City:SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733-1346
Mailing Address - Country:US
Mailing Address - Phone:631-974-5018
Mailing Address - Fax:
Practice Address - Street 1:2 STONE GATE CT
Practice Address - Street 2:
Practice Address - City:SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-1346
Practice Address - Country:US
Practice Address - Phone:631-974-5018
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-19
Last Update Date:2014-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY125543-12083A0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083A0100XAllopathic & Osteopathic PhysiciansPreventive MedicineAerospace Medicine