1194921452 NPI number — CARL DANIEL JORDAN DO

Table of content: CARL DANIEL JORDAN DO (NPI 1194921452)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194921452 NPI number — CARL DANIEL JORDAN DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JORDAN
Provider First Name:
CARL
Provider Middle Name:
DANIEL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
JORDAN
Provider Other First Name:
C
Provider Other Middle Name:
DANIEL
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DO
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1194921452
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/09/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
101 CROWN POINTE BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILLOW PARK
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76087-1191
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-757-1675
Provider Business Mailing Address Fax Number:
817-757-1676

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 CROWN POINTE BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILLOW PARK
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76087-1191
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-757-1675
Provider Business Practice Location Address Fax Number:
817-757-1676
Provider Enumeration Date:
06/25/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  P1774 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)