Provider Demographics
NPI:1720060791
Name:JORDAN, JOHN E (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:E
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:DEPT LA 21552
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91185-1552
Mailing Address - Country:US
Mailing Address - Phone:949-263-8600
Mailing Address - Fax:949-263-1639
Practice Address - Street 1:4101 TORRANCE BLVD
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503
Practice Address - Country:US
Practice Address - Phone:310-303-5750
Practice Address - Fax:310-303-5709
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2013-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG600132085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G600130Medicaid
CA00G600130OtherBLUE SHIELD
CAWG60013MMedicare PIN
CAP00323739Medicare PIN
CABT402ZMedicare PIN
CA00G600130OtherBLUE SHIELD
F16232Medicare UPIN