=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558312637
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RALPH K. JACKSON M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/13/2006
-----------------------------------------------------
Last Update Date | 12/08/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1727 AMSTERDAM AVE 3RD FLOOR
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10031-4611
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-283-0333
-----------------------------------------------------
Fax | 212-234-4954
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 601
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10031-0601
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-283-0333
-----------------------------------------------------
Fax | 212-234-4954
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number | 127939
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------