Provider Demographics
NPI:1154942266
Name:DEMCHUK, JORDAN (MD)
Entity type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:
Last Name:DEMCHUK
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 1:1200 E MICHIGAN AVE STE 245
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48912-1897
Mailing Address - Country:US
Mailing Address - Phone:517-364-5710
Mailing Address - Fax:
Practice Address - Street 1:1215 E MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912-1811
Practice Address - Country:US
Practice Address - Phone:517-364-5710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-29
Last Update Date:2023-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301509394207QA0505X
MI4351046347207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty