Provider Demographics
NPI:1033195607
Name:JACKSON, DAVID (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5700 DARROW RD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:HUDSON
Mailing Address - State:OH
Mailing Address - Zip Code:44236-5021
Mailing Address - Country:US
Mailing Address - Phone:330-656-5911
Mailing Address - Fax:330-656-5901
Practice Address - Street 1:1044 BELMONT AVE
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44504-1006
Practice Address - Country:US
Practice Address - Phone:330-746-7211
Practice Address - Fax:330-656-5901
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2019-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35059981J207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH700007026OtherRAILROAD MEDICARE
OH0805230Medicaid
OH001474708-0001OtherPENNSYLVANIA MEDICAID
OHP00360149OtherRAILROAD MEDICARE
OHJA0682521Medicare PIN
OHE33364Medicare UPIN
OH0805230Medicaid
OHJA0682525Medicare PIN