Provider Demographics
NPI:1548399538
Name:JACKSON, KEITH WAYNE (MD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:WAYNE
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 1:25108 MARGUERITE PKWY
Mailing Address - Street 2:SUITE A 203
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92692-2400
Mailing Address - Country:US
Mailing Address - Phone:949-707-5339
Mailing Address - Fax:
Practice Address - Street 1:235 N HOOVER ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90004-3627
Practice Address - Country:US
Practice Address - Phone:949-707-5339
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG46539207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G465391Medicaid
CA00G465391Medicaid
CAG46539AMedicare ID - Type Unspecified