Provider Demographics
NPI:1932151479
Name:JACKSON, ALLEN THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:ALLEN
Middle Name:THOMAS
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 1:1201 S RIDGEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-6123
Mailing Address - Country:US
Mailing Address - Phone:386-492-7718
Mailing Address - Fax:386-492-7720
Practice Address - Street 1:1201 S RIDGEWOOD AVE
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-6123
Practice Address - Country:US
Practice Address - Phone:386-492-7718
Practice Address - Fax:386-492-7720
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME80695207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001628800Medicaid
FL001628800Medicaid