Basic Information
| Provider Information | |||||||||
| NPI: | 1396275202 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BURNETTE | ||||||||
| FirstName: | JORDAN | ||||||||
| MiddleName: | DAVID | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 215 BLOOMINGDALE AVE | ||||||||
| Address2: | |||||||||
| City: | FEDERALSBURG | ||||||||
| State: | MD | ||||||||
| PostalCode: | 216321012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107549021 | ||||||||
| FaxNumber: | 3390822858 | ||||||||
| Practice Location | |||||||||
| Address1: | 215 BLOOMINGDALE AVE | ||||||||
| Address2: | |||||||||
| City: | FEDERALSBURG | ||||||||
| State: | MD | ||||||||
| PostalCode: | 216321012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107549021 | ||||||||
| FaxNumber: | 3390822858 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2017 | ||||||||
| LastUpdateDate: | 01/20/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 01/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | H0089368 | MD | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.