Provider Demographics
NPI:1770004202
Name:VOGT, JORDAN (DPM)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:VOGT
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 1:3901 DUTCHMANS LN STE 104
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-4726
Mailing Address - Country:US
Mailing Address - Phone:502-496-4914
Mailing Address - Fax:502-459-7509
Practice Address - Street 1:3901 DUTCHMANS LN STE 104
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4726
Practice Address - Country:US
Practice Address - Phone:502-496-4914
Practice Address - Fax:502-459-7509
Is Sole Proprietor?:No
Enumeration Date:2017-07-06
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN07001436A213ES0103X
KY244037213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100733760Medicaid