Provider Demographics
NPI:1922049295
Name:JACKSON, MELVIN L (MD)
Entity Type:Individual
Prefix:MR
First Name:MELVIN
Middle Name:L
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2550 NORTH HOLLYWOOD WAY
Mailing Address - Street 2:SUITE 204
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91505-5040
Mailing Address - Country:US
Mailing Address - Phone:818-557-0135
Mailing Address - Fax:818-557-1394
Practice Address - Street 1:1225 WILSHIRE BOULEVARD
Practice Address - Street 2:GOOD SAMARITAN HOSPITAL
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-2395
Practice Address - Country:US
Practice Address - Phone:213-977-2423
Practice Address - Fax:213-202-7028
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-09
Last Update Date:2009-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG32876207P00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG32876OtherBLUE CROSS
00G328760OtherBLUE SHIELD
CA00G328760Medicaid
HG32876CMedicare PIN
930128073Medicare PIN
CAA45327Medicare UPIN
CI2075Medicare PIN
CAG32876OtherBLUE CROSS