Basic Information
| Provider Information | |||||||||
| NPI: | 1306898028 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JORDAN | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | MCCALL | ||||||||
| NamePrefix: | |||||||||
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| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JORDAN | ||||||||
| OtherFirstName: | BILL | ||||||||
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| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 800 W MAGNOLIA AVE | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761044611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177597000 | ||||||||
| FaxNumber: | 8177597027 | ||||||||
| Practice Location | |||||||||
| Address1: | 95 S PAGOSA BLVD | ||||||||
| Address2: | |||||||||
| City: | PAGOSA SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 811478329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9705074000 | ||||||||
| FaxNumber: | 9707311988 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 12/18/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | E1345 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207RX0202X | DR.0043185 | CO | N | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology | 207RX0202X | E1345 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology |
ID Information
| ID | Type | State | Issuer | Description | 8EF216 | 01 | TX | BCBS | OTHER | 1319550-02 | 05 | TX | MEDICAID | 1319550-08 | 05 | TX | MEDICAID | 131955009 | 05 | TX | MEDICAID |