Healthcare Provider Details

I. General information

NPI: 1235199852
Provider Name (Legal Business Name): JACKSON MEDICAL, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2006
Last Update Date: 03/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7017 37TH AVE
JACKSON HEIGHTS NY
11372-3922
US

IV. Provider business mailing address

7017 37TH AVE
JACKSON HEIGHTS NY
11372-3922
US

V. Phone/Fax

Practice location:
  • Phone: 718-565-5600
  • Fax: 718-565-5686
Mailing address:
  • Phone: 718-565-5600
  • Fax: 718-565-5686

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number225253
License Number StateNY

VIII. Authorized Official

Name: FERDOUS KHANDKER
Title or Position: PRESIDENT
Credential:
Phone: 718-565-5600