Provider Demographics
NPI:1164432357
Name:JACKSON, RICHARD BLAIR JR (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:BLAIR
Last Name:JACKSON
Suffix:JR
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 1:7950 FLOYD CURL DR
Mailing Address - Street 2:STE 101
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3916
Mailing Address - Country:US
Mailing Address - Phone:210-614-0880
Mailing Address - Fax:210-692-0301
Practice Address - Street 1:7950 FLOYD CURL DR
Practice Address - Street 2:STE 101
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3916
Practice Address - Country:US
Practice Address - Phone:210-614-0880
Practice Address - Fax:210-692-0301
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXHO488208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP08932407Medicaid
TXP08932407Medicaid
TX893240Medicare ID - Type Unspecified