Provider Demographics
NPI:1801813407
Name:RANDOLPH JACKSON, PAMELA DAWN (MD)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:DAWN
Last Name:RANDOLPH JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12605 WILLOW MARSH LANE
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20720
Mailing Address - Country:US
Mailing Address - Phone:301-262-1528
Mailing Address - Fax:804-355-6031
Practice Address - Street 1:110 IRVING ST NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20010
Practice Address - Country:US
Practice Address - Phone:800-353-0788
Practice Address - Fax:804-355-6031
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2011-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCDC 193572085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010150469Medicaid
VA010150469Medicaid
DCF07095Medicare UPIN