Provider Demographics
NPI:1821196627
Name:JACKSON, JOHN D (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:D
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2003 MEDICAL PARKWAY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401
Mailing Address - Country:US
Mailing Address - Phone:410-573-1110
Mailing Address - Fax:410-266-0714
Practice Address - Street 1:2003 MEDICAL PARKWAY
Practice Address - Street 2:SUITE 100
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401
Practice Address - Country:US
Practice Address - Phone:410-573-1110
Practice Address - Fax:410-266-0714
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2010-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD30718207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
0003OtherBCBS DC
39833001OtherBCBS MARYLAND
260079OtherMAMSI
4086280OtherAETNA
MD0400065OtherUNITED HEALTH CARE
MDP0417OtherPRINCIPAL
110046029OtherMEDICARE RAILROAD
260079OtherMDIPA
1496254OtherUNITED MINE WORKERS ASSOC
P11674OtherBCBS POINT OF SERVICE
MD157531700Medicaid
110046029OtherMEDICARE RAILROAD
39833001OtherBCBS MARYLAND