Basic Information
Provider Information
NPI: 1033556543
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: GUICE
FirstName: JORDAN
MiddleName: LANE
NamePrefix: DR.
NameSuffix:  
Credential: M.D.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 227 IRVINGTON DR
Address2:  
City: SAN ANTONIO
State: TX
PostalCode: 782094219
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: 3551 ROGER BROOKE DR
Address2:  
City: FORT SAM HOUSTON
State: TX
PostalCode: 782344504
CountryCode: US
TelephoneNumber: 2109160439
FaxNumber: 2109166658
Other Information
ProviderEnumerationDate: 05/24/2013
LastUpdateDate: 04/04/2016
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
208D00000X0101257728VAY Allopathic & Osteopathic PhysiciansGeneral Practice 

No ID Information.


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