Provider Demographics
NPI:1194354217
Name:MAXWELL, JORDAN MICHAEL (DO)
Entity type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:MICHAEL
Last Name:MAXWELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5130 GATEWAY BLVD EAST C.P.
Mailing Address - Street 2:MSC51015
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79905
Mailing Address - Country:US
Mailing Address - Phone:915-215-4480
Mailing Address - Fax:915-215-5386
Practice Address - Street 1:9849 KENWORTHY ST
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79924-4402
Practice Address - Country:US
Practice Address - Phone:915-215-5500
Practice Address - Fax:915-215-8655
Is Sole Proprietor?:No
Enumeration Date:2020-04-02
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXV1186207QS0010X, 207Q00000X
390200000X
TXBP10085708207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program