Basic Information
| Provider Information | |||||||||
| NPI: | 1144219833 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | STEVENS | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 304 | ||||||||
| Address2: | |||||||||
| City: | GLENS FALLS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 128010304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5189266992 | ||||||||
| FaxNumber: | 5189266983 | ||||||||
| Practice Location | |||||||||
| Address1: | 16 DANFORTH ST | ||||||||
| Address2: | |||||||||
| City: | HOOSICK FALLS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 120901226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5186865002 | ||||||||
| FaxNumber: | 5186861848 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2005 | ||||||||
| LastUpdateDate: | 06/03/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 120359 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00359504 | 05 | NY | MEDICAID | P00010321 | 01 | NY | RR MEDICARE | OTHER |