1780140764 NPI number — JORDAN R. FEIN DPM

Table of content: (NPI 1780140764)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780140764 NPI number — JORDAN R. FEIN DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JORDAN R. FEIN DPM
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1780140764
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/08/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6243 FAIRMONT PKWY STE 203C
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PASADENA
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77505-4047
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
832-301-9871
Provider Business Mailing Address Fax Number:
281-810-8656

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6243 FAIRMONT PKWY STE 203C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PASADENA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77505-4047
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
832-301-9871
Provider Business Practice Location Address Fax Number:
281-810-8656
Provider Enumeration Date:
02/14/2019

Additional Information

Authorized Official

Authorized Official Last Name:
FEIN
Authorized Official First Name:
JORDAN
Authorized Official Middle Name:
R
Authorized Official Title or Position:
SOLE PRACTITIONER
Authorized Official Telephone Number:
832-301-9871

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 385852401 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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