Provider Demographics
NPI:1558312637
Name:JACKSON, RALPH K (MD)
Entity Type:Individual
Prefix:DR
First Name:RALPH
Middle Name:K
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 601
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10031-0601
Mailing Address - Country:US
Mailing Address - Phone:212-283-0333
Mailing Address - Fax:212-234-4954
Practice Address - Street 1:1727 AMSTERDAM AVE
Practice Address - Street 2:3RD FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10031-4611
Practice Address - Country:US
Practice Address - Phone:212-283-0333
Practice Address - Fax:212-234-4954
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-13
Last Update Date:2017-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY127939207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00524543Medicaid
NY37A001Medicare ID - Type Unspecified
NYC09240Medicare UPIN