Provider Demographics
NPI:1407895154
Name:JORDAN, LYNDON KIRKMAN III (MD)
Entity Type:Individual
Prefix:
First Name:LYNDON
Middle Name:KIRKMAN
Last Name:JORDAN
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 19368
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27619-9368
Mailing Address - Country:US
Mailing Address - Phone:919-787-8221
Mailing Address - Fax:919-881-2079
Practice Address - Street 1:3949 BROWNING PL
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-6504
Practice Address - Country:US
Practice Address - Phone:919-787-8221
Practice Address - Fax:919-881-2079
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2018-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC95-009612085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC16-55210OtherUNITED HEALTHCARE
NC92583OtherMEDCOST
NC92585OtherMEDCOST
NC10042OtherBLUECROSS BLUESHIELD
NC300105902OtherRAILROAD MEDICARE
NC88076OtherMEDCOST
NC8910042Medicaid
NC16-55297OtherUNITED HEALTHCARE
NC16-55299OtherUNITED HEALTHCARE
NC300105903OtherRAILROAD MEDICARE
NC300105905OtherRAILROAD MEDICARE
NC2258621BMedicare ID - Type Unspecified