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NPI Code Detail

MEDICARE: DR. IVAN D. JACKSON MD

MEDICARE: DR. IVAN D. JACKSON MD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207R00000XInternal Medicine Physician11508AL

Medicare Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
2110082048OTHERRAILROAD MEDICARE

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1205839362
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. IVAN D. JACKSON MD
Provider Business Mailing Address
First Line : 210 WESTSIDE DR
Second Line :
City : DOTHAN
State : AL
Zip : 36303-1928
Country : US
Telephone Number : 334-793-5074
Fax Number : 334-793-6460
Provider Business Practice Location Address
First Line : 210 WESTSIDE DR
Second Line :
City : DOTHAN
State : AL
Zip : 36303-1928
Country : US
Telephone Number : 334-793-5074
Fax Number : 334-793-6460
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/23/2005
Last Update Date : 03/03/2021

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Directions to “ DR. IVAN D. JACKSON MD” Practice Location

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