Provider Demographics
NPI:1154308997
Name:JACKSON, THOMAS L (MD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:L
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 1:2450 N PARK DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:IN
Mailing Address - Zip Code:47203-2292
Mailing Address - Country:US
Mailing Address - Phone:812-376-8997
Mailing Address - Fax:812-373-5323
Practice Address - Street 1:2450 N PARK DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47203-2216
Practice Address - Country:US
Practice Address - Phone:812-376-8997
Practice Address - Fax:812-373-5323
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-22
Last Update Date:2010-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01046379A174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN01046379AOtherSTATE LICENSE NUMBER
IN200134430BMedicaid
ING51947Medicare UPIN
IN179500Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER