Provider Demographics
NPI:1780446500
Name:DORELUS, JORDAN ANIEL (MMSC)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:ANIEL
Last Name:DORELUS
Suffix:
Gender:M
Credentials:MMSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 SEATON RD APT 4
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06902-3216
Mailing Address - Country:US
Mailing Address - Phone:203-685-5401
Mailing Address - Fax:
Practice Address - Street 1:20 YORK ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-3220
Practice Address - Country:US
Practice Address - Phone:203-688-4242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-26
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT23.006496363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical