Provider Demographics
NPI:1396275202
Name:BURNETTE, JORDAN DAVID (DO)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:DAVID
Last Name:BURNETTE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 BLOOMINGDALE AVE
Mailing Address - Street 2:
Mailing Address - City:FEDERALSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:21632-1012
Mailing Address - Country:US
Mailing Address - Phone:410-754-9021
Mailing Address - Fax:339-082-2858
Practice Address - Street 1:215 BLOOMINGDALE AVE
Practice Address - Street 2:
Practice Address - City:FEDERALSBURG
Practice Address - State:MD
Practice Address - Zip Code:21632-1012
Practice Address - Country:US
Practice Address - Phone:410-754-9021
Practice Address - Fax:339-082-2858
Is Sole Proprietor?:No
Enumeration Date:2017-06-13
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDH0089368207Q00000X
PAOT017834390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program