Provider Demographics
NPI:1588755862
Name:JORDAN, MICHAEL ARTHUR (OD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ARTHUR
Last Name:JORDAN
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 1:3925 PRIVATE ROAD 304
Mailing Address - Street 2:
Mailing Address - City:SEMMES
Mailing Address - State:AL
Mailing Address - Zip Code:36575-6043
Mailing Address - Country:US
Mailing Address - Phone:251-649-6848
Mailing Address - Fax:
Practice Address - Street 1:3063 DAUPHIN ST
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36606-4040
Practice Address - Country:US
Practice Address - Phone:251-476-2743
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS795TA318152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALU57550Medicare UPIN