Provider Demographics
NPI:1003917956
Name:JORDAN, RANDALL W (OD)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:W
Last Name:JORDAN
Suffix:
Gender:M
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:PO BOX 5103
Mailing Address - Street 2:
Mailing Address - City:CORDELE
Mailing Address - State:GA
Mailing Address - Zip Code:31010-5103
Mailing Address - Country:US
Mailing Address - Phone:229-273-0018
Mailing Address - Fax:229-273-0102
Practice Address - Street 1:1107 E SOUTH GREER STREET
Practice Address - Street 2:
Practice Address - City:CORDELE
Practice Address - State:GA
Practice Address - Zip Code:31015
Practice Address - Country:US
Practice Address - Phone:229-273-0018
Practice Address - Fax:229-273-0102
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1192152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00414455FMedicaid
GAGRP6776Medicare ID - Type Unspecified
GA00414455FMedicaid
U22421Medicare UPIN