Provider Demographics
NPI:1326134602
Name:JACKSON, GILCHRIST LEWIS (MD)
Entity Type:Individual
Prefix:MR
First Name:GILCHRIST
Middle Name:LEWIS
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 1:7515 S. MAIN ST. SUITE 740
Mailing Address - Street 2:TEXAS ONCOLOGY
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030
Mailing Address - Country:US
Mailing Address - Phone:713-795-0202
Mailing Address - Fax:713-799-8290
Practice Address - Street 1:7515 S. MAIN ST. SUITE 740
Practice Address - Street 2:TEXAS ONCOLOGY
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030
Practice Address - Country:US
Practice Address - Phone:713-795-0202
Practice Address - Fax:713-799-8290
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE7628208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX101150403Medicaid
TX101150401Medicaid
TX101150404Medicaid
TX101150405Medicaid
TX101150407Medicaid
TX101150406Medicaid
TX474608YQCCMedicare PIN
TX101150405Medicaid
TX101150407Medicaid
TX8A2044Medicare PIN
TX808147Medicare PIN
TX474608YKYCMedicare PIN