Provider Demographics
NPI:1730197658
Name:JORGENSEN, BRIAN K (MD)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:K
Last Name:JORGENSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:18404 N TATUM BLVD
Mailing Address - Street 2:SUITE 205
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-1509
Mailing Address - Country:US
Mailing Address - Phone:602-971-5500
Mailing Address - Fax:602-944-0504
Practice Address - Street 1:18404 N TATUM BLVD
Practice Address - Street 2:SUITE 205
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-1509
Practice Address - Country:US
Practice Address - Phone:602-971-5500
Practice Address - Fax:602-944-0504
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2011-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ25981207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
110213981OtherRR MEDICARE
25981OtherAZ LICENSE
25981OtherAZ LICENSE
63519Medicare ID - Type Unspecified