Provider Demographics
NPI:1962511535
Name:JACKSON, MELVIN (MD)
Entity Type:Individual
Prefix:
First Name:MELVIN
Middle Name:
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 1:120 HUDSON WAY
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31216-6188
Mailing Address - Country:US
Mailing Address - Phone:478-788-0404
Mailing Address - Fax:
Practice Address - Street 1:777 HEMLOCK ST
Practice Address - Street 2:HB 64
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-2102
Practice Address - Country:US
Practice Address - Phone:478-633-2097
Practice Address - Fax:478-633-7836
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA039134207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA08BDQBLMedicare ID - Type Unspecified
G98383Medicare UPIN