1497071625 NPI number — DR. M.E. JACKSON OPTOMETRIST PC

Table of content: (NPI 1497071625)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497071625 NPI number — DR. M.E. JACKSON OPTOMETRIST PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DR. M.E. JACKSON OPTOMETRIST PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
DR. M.E. JACKSON O.D., P.C.
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1497071625
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/13/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4642 HAYGOOD RD
Provider Second Line Business Mailing Address:
SUITE 1
Provider Business Mailing Address City Name:
VIRGINIA BEACH
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23455-5436
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-464-5842
Provider Business Mailing Address Fax Number:
757-464-4745

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4642 HAYGOOD RD
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
VIRGINIA BEACH
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23455-5436
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-464-5842
Provider Business Practice Location Address Fax Number:
757-464-4745
Provider Enumeration Date:
04/13/2010

Additional Information

Authorized Official

Authorized Official Last Name:
JACKSON
Authorized Official First Name:
MELVIN
Authorized Official Middle Name:
EUGENE
Authorized Official Title or Position:
DOCTOR/ SOLE OWNER
Authorized Official Telephone Number:
757-464-5842

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  0618000174 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1588657217 . This is a "NPI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0092-0598-5 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 040971 . This is a "BLUE CROSS & BLUE SHIELD" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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