Provider Demographics
NPI:1790081701
Name:TAILLON, JORDAN KRISTOFER (MD)
Entity Type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:KRISTOFER
Last Name:TAILLON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-8260
Mailing Address - Fax:239-343-8261
Practice Address - Street 1:5216 CLAYTON CT
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-2116
Practice Address - Country:US
Practice Address - Phone:239-343-8260
Practice Address - Fax:239-424-2442
Is Sole Proprietor?:No
Enumeration Date:2011-02-08
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME128602207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL018006400Medicaid