Provider Demographics
NPI:1649615287
Name:JACKSON, DOREEN ONIPEDE (MD)
Entity type:Individual
Prefix:MRS
First Name:DOREEN
Middle Name:ONIPEDE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 BODIN CIRCLE
Mailing Address - Street 2:DAVID GRANT MEDICAL CENTER - TRAVIS AIR FORCE BASE
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94535
Mailing Address - Country:US
Mailing Address - Phone:919-753-6879
Mailing Address - Fax:
Practice Address - Street 1:101 BODIN CIRCLE
Practice Address - Street 2:
Practice Address - City:TRAVIS AIR FORCE BASE
Practice Address - State:CA
Practice Address - Zip Code:94535-1800
Practice Address - Country:US
Practice Address - Phone:919-753-6879
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-09
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171636208600000X, 208C00000X
FLME139661208C00000X
NC204413208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice