Provider Demographics
NPI:1144219833
Name:JACKSON, DAVID STEVENS (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:STEVENS
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:PO BOX 304
Mailing Address - Street 2:
Mailing Address - City:GLENS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12801-0304
Mailing Address - Country:US
Mailing Address - Phone:518-926-6992
Mailing Address - Fax:518-926-6983
Practice Address - Street 1:16 DANFORTH ST
Practice Address - Street 2:
Practice Address - City:HOOSICK FALLS
Practice Address - State:NY
Practice Address - Zip Code:12090-1226
Practice Address - Country:US
Practice Address - Phone:518-686-5002
Practice Address - Fax:518-686-1848
Is Sole Proprietor?:No
Enumeration Date:2005-10-17
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY120359207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00359504Medicaid
NYP00010321OtherRR MEDICARE
NYP00010321OtherRR MEDICARE
B80690Medicare UPIN