Provider Demographics
NPI:1104893171
Name:GOETZ, JORDAN (MD)
Entity type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:
Last Name:GOETZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:YALESVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06492
Mailing Address - Country:US
Mailing Address - Phone:203-284-9099
Mailing Address - Fax:203-284-8107
Practice Address - Street 1:60 CHURCH ST
Practice Address - Street 2:
Practice Address - City:YALESVILLE
Practice Address - State:CT
Practice Address - Zip Code:06492
Practice Address - Country:US
Practice Address - Phone:203-284-9099
Practice Address - Fax:203-284-8107
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT031252207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTG18367Medicare UPIN