Basic Information
| Provider Information | |||||||||
| NPI: | 1881198588 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ABBOTT | ||||||||
| FirstName: | JORDAN | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2946 E BANNER GATEWAY DR | ||||||||
| Address2: | |||||||||
| City: | GILBERT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852342165 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4802566444 | ||||||||
| FaxNumber: | 4802563682 | ||||||||
| Practice Location | |||||||||
| Address1: | 2946 E BANNER GATEWAY DR | ||||||||
| Address2: | |||||||||
| City: | GILBERT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852342165 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4802566444 | ||||||||
| FaxNumber: | 4802563682 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2018 | ||||||||
| LastUpdateDate: | 10/03/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 66267 | AZ | Y | Allopathic & Osteopathic Physicians | Dermatology | 207N00000X | T2567 | TX | N | Allopathic & Osteopathic Physicians | Dermatology | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.