Provider Demographics
NPI:1700868106
Name:JACKSON, WILLIAM THOMAS (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
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:P.O. BOX 1350
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28115-1350
Mailing Address - Country:US
Mailing Address - Phone:704-799-3380
Mailing Address - Fax:704-799-6315
Practice Address - Street 1:131 MEDICAL PARK ROAD
Practice Address - Street 2:SUITE 204
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-8524
Practice Address - Country:US
Practice Address - Phone:704-664-5633
Practice Address - Fax:704-664-5631
Is Sole Proprietor?:No
Enumeration Date:2005-11-19
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2002-01368207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891321PMedicaid
NC010724821OtherTIN NUMBER
NC010724821OtherTIN NUMBER
NCA80795Medicare UPIN