Provider Demographics
NPI:1043577216
Name:JACKSON, WILLIAM MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:MICHAEL
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 1:622 W 168TH ST PH 5-505
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-3720
Mailing Address - Country:US
Mailing Address - Phone:646-703-4190
Mailing Address - Fax:
Practice Address - Street 1:630 W 168TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-3725
Practice Address - Country:US
Practice Address - Phone:212-305-2069
Practice Address - Fax:212-305-3204
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-12
Last Update Date:2017-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY274685207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology