Healthcare Provider Details

I. General information

NPI: 1982801130
Provider Name (Legal Business Name): TIMOTHY D JORDAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2007
Last Update Date: 03/29/2021
Certification Date: 03/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2709 BLUE RIDGE RD STE 100
RALEIGH NC
27607-6462
US

IV. Provider business mailing address

2709 BLUE RIDGE RD STE 100
RALEIGH NC
27607-6462
US

V. Phone/Fax

Practice location:
  • Phone: 919-782-5400
  • Fax: 919-782-1680
Mailing address:
  • Phone: 919-782-5400
  • Fax: 919-782-1680

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207WX0110X
TaxonomyPediatric Ophthalmology and Strabismus Specialist Physician Physician
License Number9800583
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number9800583
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: