Provider Demographics
NPI:1083613848
Name:BROWN, JORDAN DAVID (DO)
Entity Type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:DAVID
Last Name:BROWN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4165 ANDREA DR NW
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97304-3339
Mailing Address - Country:US
Mailing Address - Phone:503-581-4411
Mailing Address - Fax:503-581-2241
Practice Address - Street 1:1097 LIBERTY ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-4140
Practice Address - Country:US
Practice Address - Phone:503-581-4411
Practice Address - Fax:503-581-4411
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-14
Last Update Date:2007-11-08
Deactivation Date:2006-03-17
Deactivation Code:
Reactivation Date:2006-03-31
Provider Licenses
StateLicense IDTaxonomies
OR1515152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR0000WFBNHMedicare PIN
ORT67462Medicare UPIN
ORR00WFBNHBMedicare PIN