Provider Demographics
NPI:1962462317
Name:JORDAN, BARRY WAYNE (MD)
Entity Type:Individual
Prefix:
First Name:BARRY
Middle Name:WAYNE
Last Name:JORDAN
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:PO BOX 1547
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-1547
Mailing Address - Country:US
Mailing Address - Phone:706-868-3100
Mailing Address - Fax:
Practice Address - Street 1:465 N BELAIR RD
Practice Address - Street 2:SUITE 1B
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-3188
Practice Address - Country:US
Practice Address - Phone:706-868-3100
Practice Address - Fax:706-228-3125
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2010-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA057377207Q00000X
ARE-4171207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR156121001Medicaid
ARI21548Medicare UPIN
AR156121001Medicaid