Provider Demographics
NPI:1538172481
Name:JORDAN, GEORGE W (MD)
Entity type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:W
Last Name:JORDAN
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 1:632 W GIBSON RD
Mailing Address - Street 2:
Mailing Address - City:WOODLAND
Mailing Address - State:CA
Mailing Address - Zip Code:95695-5169
Mailing Address - Country:US
Mailing Address - Phone:530-666-1631
Mailing Address - Fax:
Practice Address - Street 1:632 W GIBSON RD
Practice Address - Street 2:
Practice Address - City:WOODLAND
Practice Address - State:CA
Practice Address - Zip Code:95695-5169
Practice Address - Country:US
Practice Address - Phone:530-666-1631
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2009-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG10213207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G102130Medicaid
CA00G102130OtherBLUE SHIELD
CA110236890OtherRR MEDICARE
CA00G102130Medicare ID - Type Unspecified
CACE869ZMedicare PIN
CA00G102130OtherBLUE SHIELD
A37898Medicare UPIN