Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207X00000X | Orthopaedic Surgeon | 49686 | AZ |
Y | 207XS0117X | Orthopaedic Spine Surgeon | 49686 | AZ |
N | 207XS0117X | Orthopaedic Spine Surgeon | A120606 | CA |
NPI | 1144364696 |
---|---|
Provider Name | David M. Jackson |
First Address | Phoenix, AZ 85023-1261 |
Second Address | Phoenix, AZ 85037-3328 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/02/2007 |
Last Update Date | 23/12/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
958173 | (05) | AZ |
PENDING | MEDICARE AZ (01) | AZ |