Provider Demographics
NPI:1003828120
Name:JORDAN-FLICKINGER, MARY ELIZABETH (OD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:JORDAN-FLICKINGER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 MIFFLIN AVE
Mailing Address - Street 2:
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18503
Mailing Address - Country:US
Mailing Address - Phone:570-342-3145
Mailing Address - Fax:570-344-1309
Practice Address - Street 1:200 MIFFLIN AVE
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18503
Practice Address - Country:US
Practice Address - Phone:570-342-3145
Practice Address - Fax:570-344-1309
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA0EG000412152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001748348Medicaid
JO461605OtherHIGH MARK BLUE SHIELD
52607OtherGEISINGER HEALTH PLAN
506554OtherAETNA
410039580OtherRAILROAD MEDICARE
811745OtherFIRST PRIORITY HEALTH
PA027907Medicare ID - Type Unspecified
811745OtherFIRST PRIORITY HEALTH