Provider Demographics
NPI:1114956562
Name:JACKSON, MARK L (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:L
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:PO BOX 14687
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85267-4687
Mailing Address - Country:US
Mailing Address - Phone:480-991-8100
Mailing Address - Fax:480-992-1028
Practice Address - Street 1:11209 N TATUM BLVD
Practice Address - Street 2:SUITE 110
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85028-3091
Practice Address - Country:US
Practice Address - Phone:602-248-8002
Practice Address - Fax:602-248-8399
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
AZ154322085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZWDBBFMedicare ID - Type Unspecified