Provider Demographics
NPI:1689674533
Name:MILFORD DIAGNOSTIC IMAGINE PA
Entity Type:Organization
Organization Name:MILFORD DIAGNOSTIC IMAGINE PA
Other - Org Name:MILFORD DIAGNOSTIC IMAGING
Other - Org Type:Other Name
Authorized Official - Title/Position:HEAD DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:JEFFERY
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:610-459-3113
Mailing Address - Street 1:21 W CLARKE AVE
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:DE
Mailing Address - Zip Code:19963-1840
Mailing Address - Country:US
Mailing Address - Phone:610-459-3113
Mailing Address - Fax:
Practice Address - Street 1:21 W CLARKE AVE
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:DE
Practice Address - Zip Code:19963-1840
Practice Address - Country:US
Practice Address - Phone:610-459-3113
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0000603202Medicaid
DE0000603202Medicaid