Provider Demographics
NPI:1851682470
Name:JOHNSON, JORDAN S (MD)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:S
Last Name:JOHNSON
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 1:9821 S MAY AVE STE C
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73159-7042
Mailing Address - Country:US
Mailing Address - Phone:405-691-0505
Mailing Address - Fax:405-691-0507
Practice Address - Street 1:9821 S MAY AVE STE C
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73159-7042
Practice Address - Country:US
Practice Address - Phone:405-691-0505
Practice Address - Fax:405-691-0507
Is Sole Proprietor?:No
Enumeration Date:2011-04-30
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.207583207W00000X
390200000X
OK32660207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04679764Medicaid
LA2144120Medicaid
LA413416YH3UMedicare PIN