Provider Demographics
NPI:1871224501
Name:PRIETO JORDAN, JOSE LUIS (MD)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:LUIS
Last Name:PRIETO 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 1:1133 SOUTH BLVD APT 617
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-3280
Mailing Address - Country:US
Mailing Address - Phone:201-897-1523
Mailing Address - Fax:
Practice Address - Street 1:3249 OAK PARK AVE
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-3429
Practice Address - Country:US
Practice Address - Phone:708-783-3401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-22
Last Update Date:2022-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.080318390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program