Provider Demographics
NPI:1457310518
Name:JACKSON, RANDOLPH THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:RANDOLPH
Middle Name:THOMAS
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 1:4801 S CLIFF AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64055-7015
Mailing Address - Country:US
Mailing Address - Phone:816-350-4536
Mailing Address - Fax:816-350-4585
Practice Address - Street 1:11010 HASKELL AVE
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66109-8500
Practice Address - Country:US
Practice Address - Phone:816-478-1230
Practice Address - Fax:816-350-4166
Is Sole Proprietor?:No
Enumeration Date:2006-03-18
Last Update Date:2009-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN46566207W00000X
MT10506207W00000X
KS31896207W00000X
MO2006012805207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSP00685107OtherRAILROAD MEDICARE
KSP00685107OtherRAILROAD MEDICARE
180001168Medicare ID - Type Unspecified