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NPI Code Detail

MEDICARE: RICHARD T JACKSON D.P.M.

MEDICARE: RICHARD T JACKSON D.P.M.
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
1213E00000XPodiatrist07000729AIN

Medicare Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
2480026551OTHERRAILROAD 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
300000089403OTHERANTHEM

General Provider Information

NPI Number : 1407859424
Entity Type Code : Individual
Provider Name (Legal Business Name) : RICHARD T JACKSON D.P.M.
Provider Business Mailing Address
First Line : PO BOX 2526
Second Line :
City : FORT WAYNE
State : IN
Zip : 46801-2526
Country : US
Telephone Number : 260-436-8686
Fax Number : 260-436-8585
Provider Business Practice Location Address
First Line : 7601 W JEFFERSON BLVD
Second Line :
City : FORT WAYNE
State : IN
Zip : 46804-4133
Country : US
Telephone Number : 260-436-8686
Fax Number : 260-486-8585
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/23/2005
Last Update Date : 11/07/2016

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