Provider Demographics
NPI:1598765083
Name:JACKSON, THOMAS MILES (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:MILES
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 1:1100 CARSON AVE
Mailing Address - Street 2:
Mailing Address - City:LA JUNTA
Mailing Address - State:CO
Mailing Address - Zip Code:81050-2751
Mailing Address - Country:US
Mailing Address - Phone:719-383-5142
Mailing Address - Fax:719-383-5140
Practice Address - Street 1:2201 SAN JUAN AVE
Practice Address - Street 2:
Practice Address - City:LA JUNTA
Practice Address - State:CO
Practice Address - Zip Code:81050-3323
Practice Address - Country:US
Practice Address - Phone:719-384-8181
Practice Address - Fax:719-384-4872
Is Sole Proprietor?:No
Enumeration Date:2005-07-26
Last Update Date:2010-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-21320208600000X
AK5568208600000X
CODR48817208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100131110BMedicaid
KS52680Medicare ID - Type Unspecified
KS100131110BMedicaid