Provider Demographics
NPI:1700103041
Name:VIRBALAS, JORDAN MICHAEL
Entity Type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:MICHAEL
Last Name:VIRBALAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JORDAN
Other - Middle Name:MICHAEL
Other - Last Name:VIRBALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:536 BERGEN ST
Mailing Address - Street 2:APT 3R
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11217-4001
Mailing Address - Country:US
Mailing Address - Phone:617-501-0198
Mailing Address - Fax:
Practice Address - Street 1:3400 BAINBRIDGE AVE
Practice Address - Street 2:DEPT OF OTOLARYNGOLOGY, 3RD FLOOR
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-2404
Practice Address - Country:US
Practice Address - Phone:617-501-0198
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-27
Last Update Date:2010-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYAB1876296207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology