Provider Demographics
NPI:1699808162
Name:JORDAN ROSEN OD LTD
Entity Type:Organization
Organization Name:JORDAN ROSEN OD LTD
Other - Org Name:MIDLOTHIAN OPTOMETRIC CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JORDAN
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:ROSEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:804-379-1872
Mailing Address - Street 1:1306 ALVERSER PLZ
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23113-2604
Mailing Address - Country:US
Mailing Address - Phone:804-379-1872
Mailing Address - Fax:804-379-0772
Practice Address - Street 1:1306 ALVERSER PLZ
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23113-2604
Practice Address - Country:US
Practice Address - Phone:804-379-1872
Practice Address - Fax:804-379-0772
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2008-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618001124152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAT81466Medicare UPIN
VAC08343Medicare PIN
VA4484220001Medicare NSC