Provider Demographics
NPI:1386713709
Name:JORDAN, JUDY L (MD)
Entity type:Individual
Prefix:DR
First Name:JUDY
Middle Name:L
Last Name:JORDAN
Suffix:
Gender:F
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:PO BOX 730
Mailing Address - Street 2:4901 WAIAKALUA ST
Mailing Address - City:KILAUEA
Mailing Address - State:HI
Mailing Address - Zip Code:96754-0730
Mailing Address - Country:US
Mailing Address - Phone:808-828-1645
Mailing Address - Fax:
Practice Address - Street 1:4901 WAIAKALUA
Practice Address - Street 2:
Practice Address - City:KILAUEA
Practice Address - State:HI
Practice Address - Zip Code:96754-0730
Practice Address - Country:US
Practice Address - Phone:808-828-1645
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD5440207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
0000BDPTGMedicare ID - Type Unspecified
E18092Medicare UPIN