1215360243 NPI number — DR. JORDAN STEPHEN PROCTOR PHARM.D.

Table of content: DR. JORDAN STEPHEN PROCTOR PHARM.D. (NPI 1215360243)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215360243 NPI number — DR. JORDAN STEPHEN PROCTOR PHARM.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PROCTOR
Provider First Name:
JORDAN
Provider Middle Name:
STEPHEN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHARM.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:
1215360243
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/13/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3668 S DALLAS ST
Provider Second Line Business Mailing Address:
210
Provider Business Mailing Address City Name:
AURORA
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80014-7439
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
720-231-3967
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3668 S DALLAS ST
Provider Second Line Business Practice Location Address:
210
Provider Business Practice Location Address City Name:
AURORA
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80014-7439
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
720-231-3967
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/13/2013

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: 183500000X , with the licence number:  19977 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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