1124206487 NPI number — BRADLEY A JACKSON M.D.

Table of content: BRADLEY A JACKSON M.D. (NPI 1124206487)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124206487 NPI number — BRADLEY A JACKSON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACKSON
Provider First Name:
BRADLEY
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1124206487
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/01/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
300 PASTEUR DR, ROOM H3630, MC: 5642
Provider Second Line Business Mailing Address:
STANFORD UNIVERSITY MED CTR, DEPT. OF INT. RADIOLOGY
Provider Business Mailing Address City Name:
STANFORD
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94305-5642
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
626-840-4287
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 E VALENCIA MESA DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FULLERTON
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92835-3809
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-992-3978
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/07/2008

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: 2085R0204X , with the licence number:  A115326 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X , with the licence number: A115326 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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