Provider Demographics
NPI:1265501126
Name:JORDAN, ROBERT B (OD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:B
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 1:622 E REELFOOT AVE
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:TN
Mailing Address - Zip Code:38261-5739
Mailing Address - Country:US
Mailing Address - Phone:731-885-0541
Mailing Address - Fax:731-885-0588
Practice Address - Street 1:622 E REELFOOT AVE
Practice Address - Street 2:
Practice Address - City:UNION CITY
Practice Address - State:TN
Practice Address - Zip Code:38261-5739
Practice Address - Country:US
Practice Address - Phone:731-885-0541
Practice Address - Fax:731-885-0588
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2009-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNODT1210152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0151506OtherBLUECROSS BLUESHIELD TN
TN6159Medicaid
TN940073OtherEYEMED
TN13835OtherSPECTRA
KY0468680001OtherNATIONAL GOVERNMENT DEMAC
TN6159Medicaid