Provider Demographics
NPI:1114916582
Name:JORDAN, BRITON PENN (MD)
Entity type:Individual
Prefix:DR
First Name:BRITON
Middle Name:PENN
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 12938
Mailing Address - Street 2:C/O CLINIC MANAGEMENT
Mailing Address - City:CALHOUN
Mailing Address - State:GA
Mailing Address - Zip Code:30703-7013
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1035 RED BUD RD NE STE 200
Practice Address - Street 2:
Practice Address - City:CALHOUN
Practice Address - State:GA
Practice Address - Zip Code:30701-6010
Practice Address - Country:US
Practice Address - Phone:706-602-8300
Practice Address - Fax:706-625-6955
Is Sole Proprietor?:No
Enumeration Date:2005-10-19
Last Update Date:2020-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA053467208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA766059410EMedicaid
GA766059410AMedicaid
GA511I020035Medicare PIN