Basic Information
| Provider Information | |||||||||
| NPI: | 1588997704 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LILIENSTEIN | ||||||||
| FirstName: | JORDAN | ||||||||
| MiddleName: | TAKEO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2625 E DIVISADERO ST | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937211431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594432682 | ||||||||
| FaxNumber: | 5594432681 | ||||||||
| Practice Location | |||||||||
| Address1: | 2823 FRESNO ST | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937211324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594593770 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2009 | ||||||||
| LastUpdateDate: | 01/15/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | A124428 | CA | N | Allopathic & Osteopathic Physicians | Surgery | 2086S0127X | A124428 | CA | N | Allopathic & Osteopathic Physicians | Surgery | Trauma Surgery | 2086S0102X | A124428 | CA | Y | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care |
No ID Information.