Provider Demographics
NPI:1659431146
Name:JORDAN, GARY CHARLES (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:CHARLES
Last Name:JORDAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 JASON LN
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:02048-3449
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:360 BROCKTON AVE
Practice Address - Street 2:
Practice Address - City:ABINGTON
Practice Address - State:MA
Practice Address - Zip Code:02351-2186
Practice Address - Country:US
Practice Address - Phone:781-878-1700
Practice Address - Fax:781-871-4375
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2013-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD08294207R00000X
MA213123207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI007009305Medicaid
RI2690610OtherAETNA
RI401734OtherBLUE CHIP
RI5631596001OtherCIGNA
RIMD08294OtherBLUE CHOICE
RI404565OtherTUFTS HEALTH PLAN
RIAA33702OtherHARVARD HEALTH PLAN
RI04-05379OtherUNITED HEALTHCARE
RI2643-9OtherBLUE CROSS
MA110078711AMedicaid
RIMD08294OtherLIFESPAN
RI27633OtherNEIGHBORHOOD HEALTH PLAN
RI2690610OtherAETNA
RI401734OtherBLUE CHIP
RI007009305Medicaid