Provider Demographics
NPI:1245236769
Name:JACKSON, RICHARD WAYNE (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:WAYNE
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:6920 GATWICK DR
Mailing Address - Street 2:STE 200
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46241-9504
Mailing Address - Country:US
Mailing Address - Phone:317-455-1064
Mailing Address - Fax:317-455-1204
Practice Address - Street 1:6920 GATWICK DR
Practice Address - Street 2:STE 200
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46241-9504
Practice Address - Country:US
Practice Address - Phone:317-455-1064
Practice Address - Fax:317-455-1204
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2016-03-10
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IN01028135207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
B18482Medicare UPIN
IN215670AMedicare PIN
IN100236350Medicaid