Healthcare Provider Details

I. General information

NPI: 1750918249
Provider Name (Legal Business Name): CLINTON JORDAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2020
Last Update Date: 07/19/2024
Certification Date: 07/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL CENTER DR
MORGANTOWN WV
26506-1200
US

IV. Provider business mailing address

1 MEDICAL CENTER DR
MORGANTOWN WV
26506-1200
US

V. Phone/Fax

Practice location:
  • Phone: 304-293-2463
  • Fax: 304-293-5160
Mailing address:
  • Phone: 304-598-4820
  • Fax: 304-598-6928

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number33807
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: