Provider Demographics
NPI:1457315947
Name:JORDAN, KIMBERLY ELIZABETH (MD)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ELIZABETH
Last Name:JORDAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 744786
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-4786
Mailing Address - Country:US
Mailing Address - Phone:704-834-2450
Mailing Address - Fax:704-671-5331
Practice Address - Street 1:2240 REMOUNT RD
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-4725
Practice Address - Country:US
Practice Address - Phone:704-865-5838
Practice Address - Fax:704-834-3817
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-08-3111-J207Q00000X
NC2010-01703207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2522569Medicaid
NC2010-01703OtherNC MEDICAL LICENSE
OH4147044Medicare PIN
OHI21404Medicare UPIN
OH2522569Medicaid
OH4147045Medicare PIN
OH4147041Medicare PIN