Provider Demographics
NPI:1659348555
Name:JACKSON, ROBERT E III (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:E
Last Name:JACKSON
Suffix:III
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:PO BOX 3856
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79116-3856
Mailing Address - Country:US
Mailing Address - Phone:806-358-4596
Mailing Address - Fax:806-358-6726
Practice Address - Street 1:1901 PORT LN
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-2430
Practice Address - Country:US
Practice Address - Phone:806-358-4596
Practice Address - Fax:806-358-6726
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2013-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE4425207U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207U00000XAllopathic & Osteopathic PhysiciansNuclear Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXE09449Medicare UPIN
TX8C9225Medicare ID - Type UnspecifiedMEDICARE NUMBER