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NPI Code Detail

MEDICARE: JOHN DANIEL JACKMAN MD

MEDICARE: JOHN DANIEL JACKMAN 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
1207RC0000XCardiovascular Disease PhysicianH1109TX
2207RI0011XInterventional Cardiology PhysicianH1109TX

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
14533990OTHERTXAETNA
289423JOTHERTXBCBS

General Provider Information

NPI Number : 1407841646
Entity Type Code : Individual
Provider Name (Legal Business Name) : JOHN DANIEL JACKMAN MD
Provider Business Mailing Address
First Line : 619 S FLEISHEL AVE
Second Line : SUITE 101
City : TYLER
State : TX
Zip : 75701-2004
Country : US
Telephone Number : 903-595-5514
Fax Number :
Provider Business Practice Location Address
First Line : 619 S FLEISHEL AVE
Second Line : SUITE 101
City : TYLER
State : TX
Zip : 75701-2004
Country : US
Telephone Number : 903-595-5514
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/14/2005
Last Update Date : 02/27/2008

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