Provider Demographics
NPI:1467411223
Name:JACKSON, ALAN E (MD)
Entity Type:Individual
Prefix:DR
First Name:ALAN
Middle Name:E
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:201 E 5900 S
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-7379
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:SUITE 101
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107-7379
Practice Address - Country:US
Practice Address - Phone:801-268-6600
Practice Address - Fax:801-268-6602
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-21
Last Update Date:2011-10-05
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
UT185984-1205207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTG77437Medicare UPIN