Provider Demographics
NPI:1881685519
Name:FERSEL, JORDAN (MD)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:FERSEL
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 1:138 W 56TH ST
Mailing Address - Street 2:
Mailing Address - City:BAYONNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07002-2210
Mailing Address - Country:US
Mailing Address - Phone:201-243-1031
Mailing Address - Fax:
Practice Address - Street 1:138 W 56TH ST
Practice Address - Street 2:
Practice Address - City:BAYONNE
Practice Address - State:NJ
Practice Address - Zip Code:07002-2210
Practice Address - Country:US
Practice Address - Phone:201-243-1031
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA049662207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0952401Medicaid
NJ0952401Medicaid
596055Medicare ID - Type Unspecified