Provider Demographics
NPI:1912004557
Name:RONALD M. JACKSON, O.D. CHARTERED
Entity Type:Organization
Organization Name:RONALD M. JACKSON, O.D. CHARTERED
Other - Org Name:DBA JACKSON & BAALMAN, DOCTORS OF OPTOMETRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:MORRIS
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:316-722-6452
Mailing Address - Street 1:982 N TYLER RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67212-3271
Mailing Address - Country:US
Mailing Address - Phone:316-722-6452
Mailing Address - Fax:316-722-6001
Practice Address - Street 1:982 N TYLER RD
Practice Address - Street 2:SUITE A
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67212-3271
Practice Address - Country:US
Practice Address - Phone:316-722-6452
Practice Address - Fax:316-722-6001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-17
Last Update Date:2012-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0982-3152W00000X
KS1293-3152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS017078Medicare PIN
KS0327130001Medicare NSC
KSCT0764Medicare ID - Type UnspecifiedRAILROAD MEDICARE