Provider Demographics
NPI:1790760197
Name:JORDAN, DOUGLAS R (OD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:R
Last Name:JORDAN
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:PO BOX 444
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:AR
Mailing Address - Zip Code:72654-0444
Mailing Address - Country:US
Mailing Address - Phone:870-424-4900
Mailing Address - Fax:870-424-4979
Practice Address - Street 1:2943 HIGHWAY 62 W
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:AR
Practice Address - Zip Code:72653-6535
Practice Address - Country:US
Practice Address - Phone:870-424-4900
Practice Address - Fax:870-424-4979
Is Sole Proprietor?:No
Enumeration Date:2005-12-08
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT 03117152W00000X
AR4021152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO108285OtherBLUE CROSS BLUE SHIELD
AR244744722Medicaid
MO316781608Medicaid
MO0420260003Medicare NSC
U44645Medicare UPIN
MO0420260001Medicare NSC
MO316781608Medicaid
MO005006128Medicare ID - Type Unspecified