Provider Demographics
NPI:1811097744
Name:JACKSON, MARILYN M (MD)
Entity type:Individual
Prefix:DR
First Name:MARILYN
Middle Name:M
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:421 W 57TH ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10019-1763
Mailing Address - Country:US
Mailing Address - Phone:212-247-8023
Mailing Address - Fax:212-247-8024
Practice Address - Street 1:421 W 57TH ST
Practice Address - Street 2:SUITE B
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-1763
Practice Address - Country:US
Practice Address - Phone:212-247-8023
Practice Address - Fax:212-247-8024
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2008-10-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY189136207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01447254Medicaid
NY01447254Medicaid
NYF65129Medicare UPIN
NY02I46ANW41Medicare PIN