Provider Demographics
NPI:1568410082
Name:JACKSON, ROBERT MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:MARK
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1500 NW 12TH AVE
Mailing Address - Street 2:JMT-EAST 1007
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33136-1028
Mailing Address - Country:US
Mailing Address - Phone:305-243-4664
Mailing Address - Fax:305-243-9927
Practice Address - Street 1:1611 NW 12TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33136-1005
Practice Address - Country:US
Practice Address - Phone:305-585-1111
Practice Address - Fax:305-575-3126
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2014-01-07
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLME 89747207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLC73518Medicare UPIN