Provider Demographics
NPI:1124083167
Name:WAYNESBOROUGH OPHTHALMOLOGY, P.A.
Entity type:Organization
Organization Name:WAYNESBOROUGH OPHTHALMOLOGY, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:FAYE
Authorized Official - Last Name:JORDAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:919-734-8440
Mailing Address - Street 1:103 COX BLVD
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27534-9478
Mailing Address - Country:US
Mailing Address - Phone:919-734-8440
Mailing Address - Fax:919-734-9387
Practice Address - Street 1:103 COX BLVD
Practice Address - Street 2:
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27534-9478
Practice Address - Country:US
Practice Address - Phone:919-734-8440
Practice Address - Fax:919-734-9387
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-20
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1019152W00000X
NC25961207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890287AMedicaid
NC0287AOtherBCBS OF NC
NC0287AOtherBCBS OF NC
NC0466930001Medicare NSC
NC1343Medicare PIN