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General NPI Number Information
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NPI Number | 1699048512
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Entity Type | Organization
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Legal Business Name | JACKSON OPHTHALMOLOGY GROUP LTD
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Dates
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Enumeration Date | 02/23/2012
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 7190 SMOKE RANCH RD STE 110
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City | LAS VEGAS
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State | NV
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Zip | 89128-8398
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Country | US
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Telephone | 702-825-2085
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Fax | 702-852-5743
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Provider Business Mailing Address
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Address Line | 8230 W SAHARA AVE SUITE 111
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City | LAS VEGAS
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State | NV
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Zip | 89117-8959
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Country | US
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Telephone | 702-472-9902
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Fax | 702-823-2135
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. TODD L JACKSON
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Credential | M.D.
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Telephone | 702-472-9902
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207W00000X
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Taxonomy Name | Ophthalmology Physician
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License Number | 13385
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License Number State | NV
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