Provider Demographics
NPI:1902231640
Name:RIDGEWAY, JORDAN (OD)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:RIDGEWAY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:JORDAN
Other - Middle Name:
Other - Last Name:RIDGEWAY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:802 MCCARTHY BLVD
Mailing Address - Street 2:
Mailing Address - City:NEW BERN
Mailing Address - State:NC
Mailing Address - Zip Code:28562-5299
Mailing Address - Country:US
Mailing Address - Phone:252-633-4183
Mailing Address - Fax:252-636-1674
Practice Address - Street 1:802 MCCARTHY BLVD
Practice Address - Street 2:
Practice Address - City:NEW BERN
Practice Address - State:NC
Practice Address - Zip Code:28562
Practice Address - Country:US
Practice Address - Phone:252-633-4183
Practice Address - Fax:252-636-1674
Is Sole Proprietor?:No
Enumeration Date:2013-09-12
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618002368152W00000X
NC2512152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist