Provider Demographics
NPI:1235131251
Name:JACKSON, ERIC M (MD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:M
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 1:16-18 RIDGE ROAD
Mailing Address - Street 2:
Mailing Address - City:NORTH ARLINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07031-6314
Mailing Address - Country:US
Mailing Address - Phone:201-997-1010
Mailing Address - Fax:201-997-7436
Practice Address - Street 1:16-18 RIDGE ROAD
Practice Address - Street 2:
Practice Address - City:NORTH RLINGTON
Practice Address - State:NJ
Practice Address - Zip Code:07031-6314
Practice Address - Country:US
Practice Address - Phone:201-997-1010
Practice Address - Fax:201-997-7436
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2014-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03676900207R00000X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
D20034Medicare UPIN
NJ476670Medicare ID - Type Unspecified