Provider Demographics
NPI:1427095942
Name:JORDAN, THEODORE R (DO)
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:R
Last Name:JORDAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 BRADENTON AVE
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43017-7515
Mailing Address - Country:US
Mailing Address - Phone:614-793-1980
Mailing Address - Fax:
Practice Address - Street 1:5131 BEACON HILL RD
Practice Address - Street 2:SUITE 200A
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43228-4442
Practice Address - Country:US
Practice Address - Phone:614-878-8034
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34-00-5892204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0190323Medicaid
OHJO0792258Medicare ID - Type Unspecified
OH0190323Medicaid