Provider Demographics
NPI:1609063775
Name:JACKSON, TODD LINCOLN (MD)
Entity Type:Individual
Prefix:DR
First Name:TODD
Middle Name:LINCOLN
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 1:710 EASTERN ST STE H
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86401-5486
Mailing Address - Country:US
Mailing Address - Phone:928-224-0536
Mailing Address - Fax:
Practice Address - Street 1:710 EASTERN ST STE H
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86401-5486
Practice Address - Country:US
Practice Address - Phone:928-224-0536
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-02
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ52840207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology