Provider Demographics
NPI:1235199852
Name:JACKSON MEDICAL, PLLC
Entity Type:Organization
Organization Name:JACKSON MEDICAL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FERDOUS
Authorized Official - Middle Name:
Authorized Official - Last Name:KHANDKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-565-5600
Mailing Address - Street 1:7017 37TH AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11372-3922
Mailing Address - Country:US
Mailing Address - Phone:718-565-5600
Mailing Address - Fax:718-565-5686
Practice Address - Street 1:7017 37TH AVE
Practice Address - Street 2:
Practice Address - City:JACKSON HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11372-3922
Practice Address - Country:US
Practice Address - Phone:718-565-5600
Practice Address - Fax:718-565-5686
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JACKSON MEDICAL, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-03-27
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY225253173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02300407Medicaid
NYWEY701Medicare PIN
NY05659Medicare ID - Type Unspecified