1891796900 NPI number — DR. DAVID SPENCER JACKSON M.D.

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891796900 NPI number — DR. DAVID SPENCER JACKSON M.D.

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

JACKSON

Provider First Name:

DAVID

Provider Middle Name:

SPENCER

Provider Name Prefix Text:

DR.

Provider Name Suffix Text:

Provider Credential Text:

M.D.

Provider Gender Code:

M

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:

1891796900

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

08/22/2019

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

7580 BUCKINGHAM BLVD STE 220

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

HANOVER

Provider Business Mailing Address State Name:

MD

Provider Business Mailing Address Postal Code:

21076-3210

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

410-729-5100

Provider Business Mailing Address Fax Number:

Provider First Line Business Practice Location Address:

11055 LITTLE PATUXENT PKWY

Provider Second Line Business Practice Location Address:

SUITE 205

Provider Business Practice Location Address City Name:

COLUMBIA

Provider Business Practice Location Address State Name:

MD

Provider Business Practice Location Address Postal Code:

21044-2896

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

410-740-0789

Provider Business Practice Location Address Fax Number:

410-740-7024

Provider Enumeration Date:

08/10/2005

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 207RC0000X , with the licence number:  D35217 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 398140-03 . This is a "CAREFIRST MD RENDERING" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
• Identifier: 4238639 . This is a "AETNA FEE FOR SERVICE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
• Identifier: P528953 . This is a "CAREFIRST MPOS" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
• Identifier: 0477972 . This is a "AETNA CAPITATED" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
• Identifier: 478471500 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
• Identifier: 060041579 . This is a "RR MEDICARE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
• Identifier: 318934 . This is a "MAMSI SPECIALIST" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
• Identifier: 3509-0006 . This is a "CAREFIRST BLUECHOICE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
• Identifier: 018410 . This is a "JHHC PROVIDER NUMBER" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
• Identifier: 0149212 . This is a "CIGNA PIN" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".