Basic Information
| Provider Information | |||||||||
| NPI: | 1740238153 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | DONALD | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6716 NW 11TH PLACE | ||||||||
| Address2: | STE 200 | ||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326054215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3523319729 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6716 NW 11TH PLACE | ||||||||
| Address2: | STE 200 | ||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326054215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3523319729 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2006 | ||||||||
| LastUpdateDate: | 03/15/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085N0700X | ME60317 | FL | N | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085R0202X | ME60317 | FL | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 054764600 | 05 | FL | MEDICAID | 12766 | 01 | FL | BCBS FL | OTHER | 239216 | 01 | FL | AVMED | OTHER | P00328037 | 01 | FL | RAILROAD MEDICARE | OTHER | P00328037 | 01 | FL | RAIL ROAD MEDICARE | OTHER | 12766 | 01 | FL | BCBSFL | OTHER | 270855 | 01 | FL | AVMED | OTHER | P00316730 | 01 | FL | RAIL ROAD MEDICARE | OTHER | 1740238153 | 01 | TRICARE PRIME | OTHER | P00316730 | 01 | FL | RAILROAD MEDICARE | OTHER |