Provider Demographics
NPI:1285603969
Name:JACKSON, SIDNEY BOGGESS (MD)
Entity type:Individual
Prefix:DR
First Name:SIDNEY
Middle Name:BOGGESS
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:278 RIDGEWAY DR
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-1152
Mailing Address - Country:US
Mailing Address - Phone:304-842-3411
Mailing Address - Fax:
Practice Address - Street 1:1 MEDICAL CENTER DRIVE
Practice Address - Street 2:LOUIS A JOHNSON VA HEALTH CARE SYSTEM
Practice Address - City:CLARKSBURG
Practice Address - State:WV
Practice Address - Zip Code:26301
Practice Address - Country:US
Practice Address - Phone:304-623-3461
Practice Address - Fax:304-626-7034
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2012-04-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WV11573207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine