Provider Demographics
NPI:1447215173
Name:JACKSON, STEVEN TAYLOR (MD)
Entity Type:Individual
Prefix:MR
First Name:STEVEN
Middle Name:TAYLOR
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:201 E 5900 S
Mailing Address - Street 2:STE 101
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-5428
Mailing Address - Country:US
Mailing Address - Phone:801-268-6600
Mailing Address - Fax:801-268-6602
Practice Address - Street 1:201 E 5900 S
Practice Address - Street 2:STE 101
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107-5428
Practice Address - Country:US
Practice Address - Phone:801-268-6600
Practice Address - Fax:801-268-6602
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1553561205207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
D07781Medicare UPIN
UT4737Medicare ID - Type Unspecified