Provider Demographics
NPI:1972616134
Name:JACKSON, RICHARD PHARUS (OD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:PHARUS
Last Name:JACKSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216 W WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:ANTHONY
Mailing Address - State:TX
Mailing Address - Zip Code:79821-9304
Mailing Address - Country:US
Mailing Address - Phone:915-886-3005
Mailing Address - Fax:915-886-3005
Practice Address - Street 1:216 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:ANTHONY
Practice Address - State:TX
Practice Address - Zip Code:79821-9304
Practice Address - Country:US
Practice Address - Phone:915-886-3005
Practice Address - Fax:915-886-3005
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4023T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00E93TMedicare ID - Type Unspecified