Provider Demographics
NPI:1164588448
Name:JACKSON, BENJAMIN MATERI (MD)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:MATERI
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 1:3400 SPRUCE STREET
Mailing Address - Street 2:4 SILVERSTEIN BUILDING
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-4206
Mailing Address - Country:US
Mailing Address - Phone:215-615-4949
Mailing Address - Fax:
Practice Address - Street 1:1259 S CEDAR CREST BLVD STE 301
Practice Address - Street 2:
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18103-6206
Practice Address - Country:US
Practice Address - Phone:610-402-9400
Practice Address - Fax:610-437-8807
Is Sole Proprietor?:No
Enumeration Date:2006-12-29
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD420325208600000X, 2086S0129X
PAMT047810T2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery