Provider Demographics
NPI:1881273399
Name:DEANGELIS, JORDAN TYLER (DO)
Entity type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:TYLER
Last Name:DEANGELIS
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 1:928 E BRENTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MORRISTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:37814-1249
Mailing Address - Country:US
Mailing Address - Phone:423-839-4155
Mailing Address - Fax:
Practice Address - Street 1:2195 HARRODSBURG RD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-3516
Practice Address - Country:US
Practice Address - Phone:859-323-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-03
Last Update Date:2021-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program