Provider Demographics
NPI:1770998478
Name:PANICCO, JORDAN (DPM)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:PANICCO
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 8TH AVE W STE 101
Mailing Address - Street 2:
Mailing Address - City:PALMETTO
Mailing Address - State:FL
Mailing Address - Zip Code:34221-4737
Mailing Address - Country:US
Mailing Address - Phone:941-776-4008
Mailing Address - Fax:941-845-4963
Practice Address - Street 1:425 NURSING HOME DR
Practice Address - Street 2:
Practice Address - City:ARCADIA
Practice Address - State:FL
Practice Address - Zip Code:34266-3839
Practice Address - Country:US
Practice Address - Phone:863-993-2966
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-23
Last Update Date:2019-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV2024213ES0103X
VA0116027378213ES0103X
FLPO4019213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV2024OtherNV MEDICAL LICENSE