Provider Demographics
NPI:1295815728
Name:JORDAN, MARY FRITZ (OD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:FRITZ
Last Name:JORDAN
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 1:923 BARCLAY CT
Mailing Address - Street 2:
Mailing Address - City:BATAVIA
Mailing Address - State:IL
Mailing Address - Zip Code:60510-3273
Mailing Address - Country:US
Mailing Address - Phone:630-406-1131
Mailing Address - Fax:630-389-0604
Practice Address - Street 1:219 E COLE AVE
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60187
Practice Address - Country:US
Practice Address - Phone:630-690-7115
Practice Address - Fax:630-690-9037
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL152WL0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
V34749Medicare UPIN
ILL54228Medicare ID - Type Unspecified