Provider Demographics
NPI:1497722151
Name:JACKSON, TAD (MD)
Entity Type:Individual
Prefix:DR
First Name:TAD
Middle Name:
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:PO BOX 3070
Mailing Address - Street 2:
Mailing Address - City:LIHUE
Mailing Address - State:HI
Mailing Address - Zip Code:96766-6070
Mailing Address - Country:US
Mailing Address - Phone:808-245-5383
Mailing Address - Fax:808-245-5380
Practice Address - Street 1:3125A ELUA ST
Practice Address - Street 2:
Practice Address - City:LIHUE
Practice Address - State:HI
Practice Address - Zip Code:96766-1212
Practice Address - Country:US
Practice Address - Phone:808-245-5383
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI10307207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIG06123Medicare UPIN
HIH101127Medicare ID - Type UnspecifiedINDIVIDUAL NUMBER