Provider Demographics
NPI:1063104982
Name:JORDAN, MICHAEL KEVIN (LDO)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:KEVIN
Last Name:JORDAN
Suffix:
Gender:M
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1580 BRANAN FIELD RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURG
Mailing Address - State:FL
Mailing Address - Zip Code:32068-8427
Mailing Address - Country:US
Mailing Address - Phone:904-214-9102
Mailing Address - Fax:904-214-9054
Practice Address - Street 1:1580 BRANAN FIELD RD
Practice Address - Street 2:
Practice Address - City:MIDDLEBURG
Practice Address - State:FL
Practice Address - Zip Code:32068-8427
Practice Address - Country:US
Practice Address - Phone:904-214-9102
Practice Address - Fax:904-214-9054
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-22
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDO5422156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician