Provider Demographics
NPI:1972537561
Name:JORDAN, ROGER L (OD)
Entity type:Individual
Prefix:DR
First Name:ROGER
Middle Name:L
Last Name:JORDAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:609 4J CT
Mailing Address - Street 2:
Mailing Address - City:GILLETTE
Mailing Address - State:WY
Mailing Address - Zip Code:82716-4135
Mailing Address - Country:US
Mailing Address - Phone:307-682-2020
Mailing Address - Fax:307-682-5656
Practice Address - Street 1:609 4J CT
Practice Address - Street 2:
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82716-4135
Practice Address - Country:US
Practice Address - Phone:307-682-2020
Practice Address - Fax:307-682-5656
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY142-T152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYW305124Medicare ID - Type Unspecified
WYU11330Medicare UPIN