Provider Demographics
NPI:1982799615
Name:JACKSON, ROBERT M (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:M
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:41250 12TH STREET WEST
Mailing Address - Street 2:SUITE C
Mailing Address - City:PALMDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93551
Mailing Address - Country:US
Mailing Address - Phone:661-224-1300
Mailing Address - Fax:661-224-1330
Practice Address - Street 1:43860 10TH ST W STE 202
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-4806
Practice Address - Country:US
Practice Address - Phone:661-729-4327
Practice Address - Fax:661-729-4227
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2010-10-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG50418207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G504180Medicare ID - Type Unspecified
CAA92976Medicare UPIN