Provider Demographics
NPI:1962575753
Name:JORDAN, MIRLANDE P (MD)
Entity type:Individual
Prefix:
First Name:MIRLANDE
Middle Name:P
Last Name:JORDAN
Suffix:
Gender:
Credentials:MD
Other - Prefix:
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Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:20 INDIGOT DR
Mailing Address - Street 2:
Mailing Address - City:SLATE HILL
Mailing Address - State:NY
Mailing Address - Zip Code:10973-4009
Mailing Address - Country:US
Mailing Address - Phone:845-701-3647
Mailing Address - Fax:
Practice Address - Street 1:43 ASHLEY AVE
Practice Address - Street 2:BUILDING 57
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10940
Practice Address - Country:US
Practice Address - Phone:845-343-6686
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2025-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2047602084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYF30428Medicare UPIN