Provider Demographics
NPI:1962406694
Name:JACKSON, GEORGE WALKER (MD)
Entity type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:WALKER
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:7430 REMCON CIR
Mailing Address - Street 2:BLDG A
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79912-3514
Mailing Address - Country:US
Mailing Address - Phone:915-584-0051
Mailing Address - Fax:915-833-1114
Practice Address - Street 1:7430 REMCON CIR
Practice Address - Street 2:BLDG A
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79912-3514
Practice Address - Country:US
Practice Address - Phone:915-584-0051
Practice Address - Fax:915-833-1114
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2016-06-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXF9613207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX81V798OtherMEDICARE
TX1303869-03Medicaid
TX130386907Medicaid
TXTXB153741OtherWELLMED PTAN
TXD66622Medicare UPIN