Provider Demographics
NPI:1932118296
Name:JORDAN, MANLEY MCRAE (MD)
Entity Type:Individual
Prefix:
First Name:MANLEY
Middle Name:MCRAE
Last Name:JORDAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 122309
Mailing Address - Street 2:DEPT 2309
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75312-2309
Mailing Address - Country:US
Mailing Address - Phone:337-494-2919
Mailing Address - Fax:337-494-3069
Practice Address - Street 1:2770 3RD AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-8994
Practice Address - Country:US
Practice Address - Phone:337-494-2750
Practice Address - Fax:337-494-2760
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2015-12-02
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
LA017837207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAP00221352OtherRAILROAD MEDICARE
LA1468444Medicaid
LA$$$$$$$$$0OtherBLUE CROSS BLUE SHIELD
LA$$$$$$$$$0OtherBLUE CROSS BLUE SHIELD
LA4J132Medicare ID - Type Unspecified