1891746707 NPI number — DR. ALFRED VAUGHN D JACKSON MD

Table of content: DR. ALFRED VAUGHN D JACKSON MD (NPI 1891746707)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891746707 NPI number — DR. ALFRED VAUGHN D JACKSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACKSON
Provider First Name:
ALFRED VAUGHN
Provider Middle Name:
D
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1891746707
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/13/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 272
Provider Second Line Business Mailing Address:
416 MAIN STREET
Provider Business Mailing Address City Name:
LA JARA
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81140-0272
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
719-274-4500
Provider Business Mailing Address Fax Number:
719-274-4504

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
416 MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LA JARA
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81140-0272
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-274-4500
Provider Business Practice Location Address Fax Number:
719-274-4504
Provider Enumeration Date:
05/15/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  1823241205 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 89132 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 31351 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 01313519 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 89132 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".