MEDICARE: DR. DANIEL G JACKSON M.D.

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
1	207YX0905X	Otolaryngology/Facial Plastic Surgery Physician	35036563	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000542269	OTHER		ANTHEM
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1447250246
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DANIEL G JACKSON M.D.

Provider Business Mailing Address
First Line	:	974 BETHEL RD
Second Line	:	SUITE A
City	:	COLUMBUS
State	:	OH
Zip	:	43214-2467
Country	:	US
Telephone Number	:	614-538-2424
Fax Number	:	614-538-2418

Provider Business Practice Location Address
First Line	:	1810 MACKENZIE DR
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43220-2967
Country	:	US
Telephone Number	:	614-273-2250
Fax Number	:	614-273-2255

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/22/2005
Last Update Date	:	02/08/2008

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