Provider Demographics
NPI:1215389812
Name:DEMARCO, JORDAN T (OD)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:T
Last Name:DEMARCO
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 1:1507 WESTOVER TER STE C
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27408-7121
Mailing Address - Country:US
Mailing Address - Phone:336-274-7771
Mailing Address - Fax:336-274-2024
Practice Address - Street 1:1507 WESTOVER TER STE C
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27408-7121
Practice Address - Country:US
Practice Address - Phone:336-274-7771
Practice Address - Fax:336-274-2024
Is Sole Proprietor?:No
Enumeration Date:2016-07-07
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG003155152W00000X
NC2489152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA13854021OtherCAQH NUMBER