Provider Demographics
NPI:1447764188
Name:BOOTH, JORDAN DANIEL (OD)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:DANIEL
Last Name:BOOTH
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 1:200 PERIMETER PARK DR STE D
Mailing Address - Street 2:
Mailing Address - City:MORRISVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27560-9714
Mailing Address - Country:US
Mailing Address - Phone:910-893-4141
Mailing Address - Fax:
Practice Address - Street 1:200 PERIMETER PARK DR STE D
Practice Address - Street 2:
Practice Address - City:MORRISVILLE
Practice Address - State:NC
Practice Address - Zip Code:27560-9714
Practice Address - Country:US
Practice Address - Phone:910-893-4141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-16
Last Update Date:2019-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2483152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist