Provider Demographics
NPI:1629009261
Name:JORDAN, LAURIE O'DANIEL (RPH, MD)
Entity Type:Individual
Prefix:DR
First Name:LAURIE
Middle Name:O'DANIEL
Last Name:JORDAN
Suffix:
Gender:F
Credentials:RPH, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 W WILSON CREEK DR
Mailing Address - Street 2:
Mailing Address - City:TRENT WOODS
Mailing Address - State:NC
Mailing Address - Zip Code:28562-7540
Mailing Address - Country:US
Mailing Address - Phone:252-636-5509
Mailing Address - Fax:252-636-5583
Practice Address - Street 1:2000 NEUSE BLVD
Practice Address - Street 2:
Practice Address - City:NEW BERN
Practice Address - State:NC
Practice Address - Zip Code:28560-3449
Practice Address - Country:US
Practice Address - Phone:252-633-8111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC30394207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8947184Medicaid
NC8947184Medicaid
NC2215877AMedicare ID - Type Unspecified