Provider Demographics
NPI:1518606391
Name:CARLSON, JORDAN (OD)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:CARLSON
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 1:294 TROY RD
Mailing Address - Street 2:
Mailing Address - City:DELAWARE
Mailing Address - State:OH
Mailing Address - Zip Code:43015-1059
Mailing Address - Country:US
Mailing Address - Phone:740-513-8719
Mailing Address - Fax:
Practice Address - Street 1:931 TIGER BLVD
Practice Address - Street 2:
Practice Address - City:CLEMSON
Practice Address - State:SC
Practice Address - Zip Code:29631-1419
Practice Address - Country:US
Practice Address - Phone:864-654-6706
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-01
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2342152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC2342OtherSC BOARD OF OPTOMETRY LICENSE