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General NPI Number Information
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NPI Number | 1326216847
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Entity Type | Organization
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Legal Business Name | KEITH RYAN JACKSON MD PC
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Dates
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Enumeration Date | 02/19/2008
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Last Update Date | 05/29/2013
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Provider Practice Location Address
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Address Line | 11 RALPH PL SUITE 209
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City | STATEN ISLAND
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State | NY
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Zip | 10304-4419
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Country | US
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Telephone | 718-727-1331
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Fax | 718-727-2159
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Provider Business Mailing Address
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Address Line | 11 RALPH PL SUITE 209
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City | STATEN ISLAND
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State | NY
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Zip | 10304-4419
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Country | US
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Telephone | 718-727-1331
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Fax | 718-727-2159
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. KEITH RYAN JACKSON
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Credential | M.D.
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Telephone | 718-727-1331
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | 212165
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License Number State | NY
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