Healthcare Provider Details

I. General information

NPI: 1457310518
Provider Name (Legal Business Name): RANDOLPH THOMAS JACKSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2006
Last Update Date: 05/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11010 HASKELL AVE
KANSAS CITY KS
66109-8500
US

IV. Provider business mailing address

4801 S CLIFF AVE SUITE 100
INDEPENDENCE MO
64055-7015
US

V. Phone/Fax

Practice location:
  • Phone: 816-478-1230
  • Fax: 816-350-4166
Mailing address:
  • Phone: 816-350-4536
  • Fax: 816-350-4585

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number46566
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number10506
License Number StateMT
# 3
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number31896
License Number StateKS
# 4
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number2006012805
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: