Provider Demographics
NPI:1174540520
Name:DE-PAZ, JORDAN (MD)
Entity type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:
Last Name:DE-PAZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3125 CONANT AVE
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-6527
Mailing Address - Country:US
Mailing Address - Phone:209-524-1668
Mailing Address - Fax:209-524-0014
Practice Address - Street 1:3125 CONANT AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-6527
Practice Address - Country:US
Practice Address - Phone:209-524-1668
Practice Address - Fax:209-524-0014
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA82325207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
BD8400513OtherDEA
BD8400513OtherDEA
I19550Medicare UPIN
CA00A823250Medicare PIN