Provider Demographics
NPI:1033177530
Name:JACKSON, MARK R (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:R
Last Name:JACKSON
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Gender:M
Credentials:MD
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Mailing Address - Street 1:3 SAINT FRANCIS DR
Mailing Address - Street 2:SUITE 330
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-3971
Mailing Address - Country:US
Mailing Address - Phone:864-255-1834
Mailing Address - Fax:864-255-1836
Practice Address - Street 1:3 SAINT FRANCIS DR
Practice Address - Street 2:SUITE 330
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29601-3971
Practice Address - Country:US
Practice Address - Phone:864-255-1834
Practice Address - Fax:864-255-1836
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2020-11-06
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Provider Licenses
StateLicense IDTaxonomies
SC235592085R0202X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89067KHMedicaid
SCT78966Medicaid
NC89067KHMedicaid
SCP00325475Medicare PIN
SCG576307895Medicare PIN
SCT78966Medicaid
SCG57630Medicare UPIN