Provider Demographics
NPI:1912991019
Name:JACKSON, MICHAEL E (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:E
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 GREENE AVE
Mailing Address - Street 2:SUITES 2D/2E
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11238
Mailing Address - Country:US
Mailing Address - Phone:718-623-2783
Mailing Address - Fax:718-623-2787
Practice Address - Street 1:55 GREENE AVE 2D/2E
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11238-6406
Practice Address - Country:US
Practice Address - Phone:718-623-2783
Practice Address - Fax:718-623-2787
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-02
Last Update Date:2015-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY177618-1207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYE74462Medicare UPIN
NY77F251Medicare ID - Type Unspecified