Provider Demographics
NPI:1942206453
Name:JACKSON, DAVID DEWITT (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:DEWITT
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1267
Mailing Address - Street 2:
Mailing Address - City:MT AIRY
Mailing Address - State:NC
Mailing Address - Zip Code:27030-1267
Mailing Address - Country:US
Mailing Address - Phone:336-786-4522
Mailing Address - Fax:336-789-3025
Practice Address - Street 1:708 S SOUTH ST
Practice Address - Street 2:STE 100
Practice Address - City:MT AIRY
Practice Address - State:NC
Practice Address - Zip Code:27030-4426
Practice Address - Country:US
Practice Address - Phone:336-789-9176
Practice Address - Fax:336-786-3778
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2015-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC18662208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1912995093OtherSURRY SURGICAL GROUP NPI
NC8945509Medicaid
NC8945509Medicaid
NC207526AMedicare PIN