Provider Demographics
NPI:1972786630
Name:JORDAN, CARLOS ALBERTO (MD)
Entity type:Individual
Prefix:
First Name:CARLOS
Middle Name:ALBERTO
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 1:200 SE HOSPITAL AVE
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34994-2346
Mailing Address - Country:US
Mailing Address - Phone:772-287-5200
Mailing Address - Fax:772-288-5834
Practice Address - Street 1:200 SE HOSPITAL AVE
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-2346
Practice Address - Country:US
Practice Address - Phone:772-287-5200
Practice Address - Fax:772-288-5834
Is Sole Proprietor?:No
Enumeration Date:2007-12-17
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME153725207R00000X
SC32623207R00000X
OH35122234207R00000X
OH57.014207390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC326230Medicaid
SCGP5462Medicaid
SCGP9493Medicare PIN
SCGP5462Medicaid