Provider Demographics
NPI:1982656880
Name:JORDAN, MARSHALL C (MD)
Entity Type:Individual
Prefix:
First Name:MARSHALL
Middle Name:C
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:PO BOX 26666
Mailing Address - Street 2:PHS PROVIDER ENROLLMENT
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-6666
Mailing Address - Country:US
Mailing Address - Phone:505-923-5356
Mailing Address - Fax:505-923-5354
Practice Address - Street 1:ESPANOLA MULTI-SPECIALTY CLINIC
Practice Address - Street 2:1010 SPRUCE ST
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532
Practice Address - Country:US
Practice Address - Phone:505-367-0340
Practice Address - Fax:505-367-0346
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2008-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2006-0824208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM29377056Medicaid
B74689Medicare UPIN
346709502Medicare PIN