Provider Demographics
NPI:1598937203
Name:O. B. JACKSON, JR.,MD, PA
Entity type:Organization
Organization Name:O. B. JACKSON, JR.,MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:OSCAR
Authorized Official - Middle Name:B
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:512-451-0234
Mailing Address - Street 1:3509 LAWTON AVE
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78731-6112
Mailing Address - Country:US
Mailing Address - Phone:512-451-0234
Mailing Address - Fax:512-451-3566
Practice Address - Street 1:3509 LAWTON AVE
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-6112
Practice Address - Country:US
Practice Address - Phone:512-451-0234
Practice Address - Fax:512-451-3566
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-02
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD8288207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX134810405Medicaid
TXW30233Medicare UPIN
TX00T035Medicare PIN