Provider Demographics
NPI:1558467043
Name:JACKSON, RALPH A (MD)
Entity Type:Individual
Prefix:
First Name:RALPH
Middle Name:A
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 1:4390 PLEASANT HILL RD STE D
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-8054
Mailing Address - Country:US
Mailing Address - Phone:770-476-2273
Mailing Address - Fax:770-476-2274
Practice Address - Street 1:4390 PLEASANT HILL RD STE D
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-8054
Practice Address - Country:US
Practice Address - Phone:770-476-2273
Practice Address - Fax:770-476-2274
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-15
Last Update Date:2012-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA022794207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00240545LMedicaid
GA582396298OtherTAX ID
GA582396298OtherTAX ID
GAD45734Medicare UPIN
GA582396298OtherTAX ID