Provider Demographics
NPI:1891796900
Name:JACKSON, DAVID SPENCER (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:SPENCER
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7580 BUCKINGHAM BLVD STE 220
Mailing Address - Street 2:
Mailing Address - City:HANOVER
Mailing Address - State:MD
Mailing Address - Zip Code:21076-3210
Mailing Address - Country:US
Mailing Address - Phone:410-729-5100
Mailing Address - Fax:
Practice Address - Street 1:11055 LITTLE PATUXENT PKWY
Practice Address - Street 2:SUITE 205
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044-2896
Practice Address - Country:US
Practice Address - Phone:410-740-0789
Practice Address - Fax:410-740-7024
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD35217207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD398140-03OtherCAREFIRST MD RENDERING
MD4238639OtherAETNA FEE FOR SERVICE
MDP528953OtherCAREFIRST MPOS
MD0477972OtherAETNA CAPITATED
MD478471500Medicaid
MD060041579OtherRR MEDICARE
MD318934OtherMAMSI SPECIALIST
MD3509-0006OtherCAREFIRST BLUECHOICE
MD018410OtherJHHC PROVIDER NUMBER
MD0149212OtherCIGNA PIN
MD478471500Medicaid
MD4238639OtherAETNA FEE FOR SERVICE