Provider Demographics
NPI:1538113311
Name:JORDAN, JOAN T (MD)
Entity Type:Individual
Prefix:DR
First Name:JOAN
Middle Name:T
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 63362
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28263-3362
Mailing Address - Country:US
Mailing Address - Phone:919-684-8111
Mailing Address - Fax:
Practice Address - Street 1:530 NEW WAVERLY PL
Practice Address - Street 2:STE 101
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27518-7414
Practice Address - Country:US
Practice Address - Phone:919-233-3959
Practice Address - Fax:919-233-1003
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2014-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC28656207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC110238722OtherRAILROAD MEDICARE PTAN
NC8947410Medicaid
NC110238722OtherRAILROAD MEDICARE PTAN
NC21183DMedicare PIN
NC8947410Medicaid