Provider Demographics
NPI:1902901937
Name:JORDAN, MARK SAUNDERS (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:SAUNDERS
Last Name:JORDAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 767
Mailing Address - Street 2:
Mailing Address - City:EDEN
Mailing Address - State:NC
Mailing Address - Zip Code:27289-0767
Mailing Address - Country:US
Mailing Address - Phone:336-623-9711
Mailing Address - Fax:336-627-0900
Practice Address - Street 1:117 E KINGS HWY
Practice Address - Street 2:
Practice Address - City:EDEN
Practice Address - State:NC
Practice Address - Zip Code:27288-5201
Practice Address - Country:US
Practice Address - Phone:336-623-9711
Practice Address - Fax:336-627-0900
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2019-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0095-00627174400000X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89132RCMedicaid
NC89132RCMedicaid
NC2015136Medicare ID - Type Unspecified