Provider Demographics
NPI:1699048512
Name:JACKSON OPHTHALMOLOGY GROUP LTD
Entity type:Organization
Organization Name:JACKSON OPHTHALMOLOGY GROUP LTD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:L
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:702-472-9902
Mailing Address - Street 1:8230 W SAHARA AVE
Mailing Address - Street 2:SUITE 111
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89117-8959
Mailing Address - Country:US
Mailing Address - Phone:702-472-9902
Mailing Address - Fax:702-823-2135
Practice Address - Street 1:7190 SMOKE RANCH RD STE 110
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-8398
Practice Address - Country:US
Practice Address - Phone:702-825-2085
Practice Address - Fax:702-852-5743
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV13385207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1609063775OtherNPI