Provider Demographics
NPI:1316988900
Name:JORDAN, ROBERT BRUCE (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:BRUCE
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 7146
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71306-0146
Mailing Address - Country:US
Mailing Address - Phone:805-901-0204
Mailing Address - Fax:318-443-2410
Practice Address - Street 1:253 WILDERNESS DR
Practice Address - Street 2:
Practice Address - City:BOYCE
Practice Address - State:LA
Practice Address - Zip Code:71409-8618
Practice Address - Country:US
Practice Address - Phone:318-443-2418
Practice Address - Fax:318-443-2410
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-08
Last Update Date:2009-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC261562085R0202X
LAMD.0091802085R0202X
TXJ12772085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0106037Medicaid
CA00C261560Medicaid
WC26156AMedicare PIN
CAWC26156FMedicare PIN
B61295Medicare UPIN
CAGR0106037Medicaid