Provider Demographics
NPI:1558584888
Name:RALPH K. JACKSON, M.D., P.C.
Entity Type:Organization
Organization Name:RALPH K. JACKSON, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RALPH
Authorized Official - Middle Name:KINER
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:212-283-0333
Mailing Address - Street 1:1727 AMSTERDAM AVE
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10031-4611
Mailing Address - Country:US
Mailing Address - Phone:212-283-0333
Mailing Address - Fax:212-234-4954
Practice Address - Street 1:1727 AMSTERDAM AVENUE
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2008-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00524543Medicaid
NYC09240Medicare UPIN
NYWZVQX1Medicare PIN