Provider Demographics
NPI:1700887189
Name:DEAN, JORDAN ARTHUR JR (MD)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:ARTHUR
Last Name:DEAN
Suffix:JR
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 1:1 INDEPENDENCE PT
Mailing Address - Street 2:SUITE 212
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4545
Mailing Address - Country:US
Mailing Address - Phone:864-797-6306
Mailing Address - Fax:
Practice Address - Street 1:111 OMNI DRIVE
Practice Address - Street 2:
Practice Address - City:SENECA
Practice Address - State:SC
Practice Address - Zip Code:29672-9448
Practice Address - Country:US
Practice Address - Phone:864-888-4222
Practice Address - Fax:864-888-0023
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2016-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10252208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP4697Medicaid
SC102524Medicaid
SC8768Medicare PIN
SCD47035Medicare UPIN
SC428913Medicare ID - Type Unspecified