Provider Demographics
NPI:1922205889
Name:JORDAN, KEVIN THEOPHILUS (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:THEOPHILUS
Last Name: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 1:2411 KILLDEER ST
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70122-4315
Mailing Address - Country:US
Mailing Address - Phone:504-897-7794
Mailing Address - Fax:504-897-7354
Practice Address - Street 1:1401 FOUCHER ST
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70115-3515
Practice Address - Country:US
Practice Address - Phone:504-897-7794
Practice Address - Fax:504-897-7354
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-02
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.130562207P00000X
LA018235207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1364371Medicaid
LAC67487Medicare UPIN
LA1364371Medicaid