Provider Demographics
NPI:1033329990
Name:JACKSON, ATIBA DIARRA (MD)
Entity Type:Individual
Prefix:
First Name:ATIBA
Middle Name:DIARRA
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:4160 LITTLE YORK RD
Mailing Address - Street 2:STE 10
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45414-5803
Mailing Address - Country:US
Mailing Address - Phone:937-415-9100
Mailing Address - Fax:937-415-9191
Practice Address - Street 1:4160 LITTLE YORK RD
Practice Address - Street 2:STE 10
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45414-5803
Practice Address - Country:US
Practice Address - Phone:937-415-9100
Practice Address - Fax:937-415-9191
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2016-09-16
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
OH35.089443207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHH488460Medicare PIN