Provider Demographics
NPI:1932169042
Name:JACKSON, CARY V (MD)
Entity Type:Individual
Prefix:DR
First Name:CARY
Middle Name:V
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 1:3340 EAST GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1026
Mailing Address - Country:US
Mailing Address - Phone:208-302-2100
Mailing Address - Fax:208-302-2125
Practice Address - Street 1:401 E HAWAII
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686
Practice Address - Country:US
Practice Address - Phone:208-302-2100
Practice Address - Fax:208-302-2125
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2016-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM5647207RP1001X
IDM-5647207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1123277Medicare PIN
IDE56058Medicare UPIN