Provider Demographics
NPI:1326083320
Name:JACKSON, THOMAS WILLIAM (MD)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:WILLIAM
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 1:4444 MAGNOLIA AVENUE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92501-4136
Mailing Address - Country:US
Mailing Address - Phone:951-682-5661
Mailing Address - Fax:951-686-3758
Practice Address - Street 1:4444 MAGNOLIA AVENUE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501-4136
Practice Address - Country:US
Practice Address - Phone:951-682-5661
Practice Address - Fax:951-686-3758
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2012-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG49810207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZZ9647Z9Medicaid
CAZZZZ9647Z9Medicaid
A51472Medicare UPIN