Provider Demographics
NPI:1730157835
Name:DUTTER, JORDAN LEE (MD)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:LEE
Last Name:DUTTER
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:PO BOX 4699
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47903-4699
Mailing Address - Country:US
Mailing Address - Phone:765-449-2732
Mailing Address - Fax:765-449-1196
Practice Address - Street 1:203 N DIVISION ST
Practice Address - Street 2:
Practice Address - City:FLORA
Practice Address - State:IN
Practice Address - Zip Code:46929-1024
Practice Address - Country:US
Practice Address - Phone:574-967-4523
Practice Address - Fax:574-967-4994
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2025-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01056529A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN9397025OtherPHCS PID NUMBER
IN200399760Medicaid
IN11319868OtherCAQH NUMBER
IN9397025OtherPHCS PID NUMBER
INH76103Medicare UPIN
ININ1862001Medicare PIN
IN200399760Medicaid
IN815500M5Medicare PIN
IN199200GMedicare PIN