Basic Information
| Provider Information | |||||||||
| NPI: | 1598706855 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | BRIAN | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7100 SIX FORKS RD | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276156156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9198470187 | ||||||||
| FaxNumber: | 9196762231 | ||||||||
| Practice Location | |||||||||
| Address1: | 6825 PARKER FARM DR | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284053168 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104520554 | ||||||||
| FaxNumber: | 9104520767 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2006 | ||||||||
| LastUpdateDate: | 11/15/2017 | ||||||||
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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 | 152W00000X | 1294 | NC | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 093VY | 01 | NC | BLUE CROSS BLUE SHIELD | OTHER | P00789509 | 01 | NC | MEDICARE RAILROAD CARRIER | OTHER | 809042B | 05 | NC | MEDICAID |