1144631268 NPI number — JORDAN THOMAS TRAUB M.D.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144631268 NPI number — JORDAN THOMAS TRAUB M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TRAUB
Provider First Name:
JORDAN
Provider Middle Name:
THOMAS
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1144631268
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/21/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3551 ROGER BROOKE DRIVE, MCHE-QD (CREDS)
Provider Second Line Business Mailing Address:
BROOKE ARMY MEDICAL CENTER
Provider Business Mailing Address City Name:
JBSA-FORT SAM HOUSTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78234-4504
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-916-5000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
590 MEDICAL CENTER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT CAVAZOS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76544-5060
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
254-553-0702
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/12/2014

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: 207R00000X , with the licence number:  0101259791 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208M00000X , with the licence number: 0101259791 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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