Provider Demographics
NPI:1649229394
Name:JORDAN DEVELOPMENTAL PEDIATRICS PC
Entity Type:Organization
Organization Name:JORDAN DEVELOPMENTAL PEDIATRICS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:JORDAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:602-956-3141
Mailing Address - Street 1:21031 N CAVE CREEK RD
Mailing Address - Street 2:STE F4
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85024-5525
Mailing Address - Country:US
Mailing Address - Phone:602-956-3141
Mailing Address - Fax:602-795-1671
Practice Address - Street 1:21031 N CAVE CREEK RD
Practice Address - Street 2:STE F4
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85024-5525
Practice Address - Country:US
Practice Address - Phone:602-956-3141
Practice Address - Fax:602-795-1671
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-09
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ269882080P0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral PediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ508658Medicaid