Provider Demographics
NPI:1912014093
Name:KHADIJAH Y. JORDAN, MD.,PC
Entity Type:Organization
Organization Name:KHADIJAH Y. JORDAN, MD.,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KHADIJAH
Authorized Official - Middle Name:Y
Authorized Official - Last Name:JORDAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:757-436-2424
Mailing Address - Street 1:111 MEDICAL PKWY
Mailing Address - Street 2:SUITE 202
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320-0302
Mailing Address - Country:US
Mailing Address - Phone:757-436-2424
Mailing Address - Fax:757-436-6628
Practice Address - Street 1:111 MEDICAL PKWY
Practice Address - Street 2:SUITE 202
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-0302
Practice Address - Country:US
Practice Address - Phone:757-436-2424
Practice Address - Fax:757-436-6628
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-24
Last Update Date:2009-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101052592207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
2133107OtherMAMSI
VA24104OtherOPTIMA
VA178986OtherANTHEM
VA010202531Medicaid
VA5025116OtherCIGNA
VA5025116OtherCIGNA
VA010202531Medicaid