Provider Demographics
NPI:1750510988
Name:DEHAVEN, JORDAN SAMUEL (DPM)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:SAMUEL
Last Name:DEHAVEN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1180 HOPE ST
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:RI
Mailing Address - Zip Code:02809-1126
Mailing Address - Country:US
Mailing Address - Phone:401-253-8900
Mailing Address - Fax:401-253-3131
Practice Address - Street 1:1180 HOPE ST
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:RI
Practice Address - Zip Code:02809-1126
Practice Address - Country:US
Practice Address - Phone:401-253-8900
Practice Address - Fax:401-253-3131
Is Sole Proprietor?:No
Enumeration Date:2009-07-09
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIDPM00328213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIJD81548Medicaid
RI001597903Medicare PIN