Provider Demographics
NPI:1255434825
Name:JACKSON, CAROL A (MD)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:A
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:361 HOSPITAL RD
Mailing Address - Street 2:STE 325
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-3522
Mailing Address - Country:US
Mailing Address - Phone:949-574-7744
Mailing Address - Fax:949-642-3686
Practice Address - Street 1:361 HOSPITAL RD
Practice Address - Street 2:STE 325
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-3522
Practice Address - Country:US
Practice Address - Phone:949-574-7744
Practice Address - Fax:949-642-3686
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-07
Last Update Date:2009-06-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG50085207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG50085Medicare PIN
CAA54901Medicare UPIN