Provider Demographics
NPI:1629076864
Name:JACKSON, BILLY MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:BILLY
Middle Name:MICHAEL
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 1:3917 WEST RD
Mailing Address - Street 2:SUITE 150
Mailing Address - City:LOS ALAMOS
Mailing Address - State:NM
Mailing Address - Zip Code:87544
Mailing Address - Country:US
Mailing Address - Phone:505-662-4351
Mailing Address - Fax:505-662-4351
Practice Address - Street 1:3917 WEST RD
Practice Address - Street 2:SUITE 150
Practice Address - City:LOS ALAMOS
Practice Address - State:NM
Practice Address - Zip Code:87544
Practice Address - Country:US
Practice Address - Phone:505-662-4351
Practice Address - Fax:505-662-4351
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM72160208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM18523Medicaid
D35724Medicare UPIN
341315701Medicare PIN