Provider Demographics
NPI:1649272311
Name:JACKSON, ROBERT M (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:M
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7800 N MOPAC EXPY
Mailing Address - Street 2:SUITE 315
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-8900
Mailing Address - Country:US
Mailing Address - Phone:512-459-4869
Mailing Address - Fax:512-453-2795
Practice Address - Street 1:7800 N MOPAC EXPY
Practice Address - Street 2:SUITE 315
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-8900
Practice Address - Country:US
Practice Address - Phone:512-459-4869
Practice Address - Fax:512-453-2795
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2012-09-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXG5206207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8204BOMedicare ID - Type Unspecified
D97424Medicare UPIN