Healthcare Provider Details

I. General information

NPI: 1275228504
Provider Name (Legal Business Name): MARANDA JORDAN DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2023
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

169 ASHLEY AVE
CHARLESTON SC
29425-0333
US

IV. Provider business mailing address

169 ASHLEY AVE
CHARLESTON SC
29425-0333
US

V. Phone/Fax

Practice location:
  • Phone: 843-792-2300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LC0200X
TaxonomyCritical Care Medicine (Anesthesiology) Physician
License Number97138
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: