Provider Demographics
NPI:1710928296
Name:JACKSON, DAVID B (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:B
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4410 WATERMELON RD
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:AL
Mailing Address - Zip Code:35473-5204
Mailing Address - Country:US
Mailing Address - Phone:205-345-1520
Mailing Address - Fax:205-345-1761
Practice Address - Street 1:4410 WATERMELON RD
Practice Address - Street 2:
Practice Address - City:NORTHPORT
Practice Address - State:AL
Practice Address - Zip Code:35473-5204
Practice Address - Country:US
Practice Address - Phone:205-345-1520
Practice Address - Fax:205-345-1761
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2010-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00018093207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051022709OtherBCBS
AL000022709Medicaid
AL51022709Medicare ID - Type Unspecified
AL051022709OtherBCBS