Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223E0200X | Endodontist | 3893-16 | MS |
N | 1223G0001X | General Practice | D3731 | ID |
N | 213EG0000X | General Practice | D3731 | ID |
NPI | 1083605711 |
---|---|
Provider Name | Jared W. Cardon |
First Address | Keesler Afb, MS 39564 |
Second Address | Keesler Afb, MS 39534-2513 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/11/2005 |
Last Update Date | 09/11/2017 |