1609843994 NPI number — DR. MARTIN JOURDEN D.O.

Table of content: DR. MARTIN JOURDEN D.O. (NPI 1609843994)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609843994 NPI number — DR. MARTIN JOURDEN D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOURDEN
Provider First Name:
MARTIN
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
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:
1609843994
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/15/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 203
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PRINCE GEORGE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23875-0203
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
804-541-6666
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
50 MEDICAL PARK BLVD.
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
PETERSBURG
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23805-9274
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
804-732-1286
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/05/2006

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: 207V00000X , with the licence number:  102201039 , 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)

  • Identifier: 6204503 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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