Provider Demographics
NPI:1205824042
Name:JORDAN, JOHN N (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:N
Last Name:JORDAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:4728 JENN DR STE 104
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29577-5714
Mailing Address - Country:US
Mailing Address - Phone:843-449-2272
Mailing Address - Fax:843-236-5088
Practice Address - Street 1:3816 HIGHWAY 17 S
Practice Address - Street 2:
Practice Address - City:NORTH MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29582-5069
Practice Address - Country:US
Practice Address - Phone:843-272-1411
Practice Address - Fax:843-272-2130
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-06
Last Update Date:2019-05-09
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
SC13156207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDB4083OtherRAILROAD MEDICARE
C61108Medicare UPIN
SC7431Medicare PIN