Provider Demographics
NPI:1124091970
Name:JACKSON, KEITH A (MD)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:A
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 500877
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92150-0877
Mailing Address - Country:US
Mailing Address - Phone:858-279-4221
Mailing Address - Fax:858-279-4223
Practice Address - Street 1:5405 OBERLIN DR FL 2
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-1700
Practice Address - Country:US
Practice Address - Phone:858-909-0770
Practice Address - Fax:858-909-0880
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-10
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG58187207Y00000X
NV8547207YX0901X, 207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
No207YX0901XAllopathic & Osteopathic PhysiciansOtolaryngologyOtology & NeurotologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002018083Medicaid
37809Medicare ID - Type Unspecified
NV002018083Medicaid