Provider Demographics
NPI:1659330108
Name:JACKSON, DEWEY THOMAS (MD)
Entity Type:Individual
Prefix:MR
First Name:DEWEY
Middle Name:THOMAS
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 1:2828 BAIRD RD
Mailing Address - Street 2:
Mailing Address - City:FAIRPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14450-1247
Mailing Address - Country:US
Mailing Address - Phone:585-248-9670
Mailing Address - Fax:585-248-0384
Practice Address - Street 1:2828 BAIRD RD
Practice Address - Street 2:
Practice Address - City:FAIRPORT
Practice Address - State:NY
Practice Address - Zip Code:14450-1247
Practice Address - Country:US
Practice Address - Phone:585-248-9670
Practice Address - Fax:585-248-0384
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY136492207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY100843BJOtherPREFERRED CARE
NY10162610OtherBLUE CHOICE
179593Medicare ID - Type Unspecified
NY10162610OtherBLUE CHOICE