Provider Demographics
NPI:1265516447
Name:JACKSON, BYRON (DPM)
Entity type:Individual
Prefix:
First Name:BYRON
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3310 MAGNOLIA ST
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29115-1466
Mailing Address - Country:US
Mailing Address - Phone:803-531-6900
Mailing Address - Fax:803-531-6907
Practice Address - Street 1:3310 MAGNOLIA ST
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29115-1466
Practice Address - Country:US
Practice Address - Phone:803-531-6900
Practice Address - Fax:803-531-6907
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2022-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC519213E00000X
GAPOD001104213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPD5195Medicaid
GA511I480OtherMEDICARE PTAN
SCPD5195Medicaid
GA511I480OtherMEDICARE PTAN