=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962462317
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BARRY WAYNE JORDAN M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/27/2006
-----------------------------------------------------
Last Update Date | 09/25/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1205 TOWN PARK LN
-----------------------------------------------------
City | EVANS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30809-3481
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-868-3100
-----------------------------------------------------
Fax | 706-228-3125
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1205 TOWN PARK LN
-----------------------------------------------------
City | EVANS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30809-3481
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-868-3100
-----------------------------------------------------
Fax | 706-228-3125
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | E-4171
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 057377
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------