Provider Demographics
NPI:1548564305
Name:MARTIN JACKSON DPM PSC
Entity Type:Organization
Organization Name:MARTIN JACKSON DPM PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:N
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:972-270-7627
Mailing Address - Street 1:1675 REPUBLIC PKWY
Mailing Address - Street 2:STE. 101
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75150-6903
Mailing Address - Country:US
Mailing Address - Phone:972-270-7627
Mailing Address - Fax:972-270-7759
Practice Address - Street 1:9300 LAKEVIEW PKWY
Practice Address - Street 2:
Practice Address - City:ROWLETT
Practice Address - State:TX
Practice Address - Zip Code:75088-4476
Practice Address - Country:US
Practice Address - Phone:972-475-4700
Practice Address - Fax:972-412-2122
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-07
Last Update Date:2011-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1239213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty