Basic Information
| Provider Information | |||||||||
| NPI: | 1881631984 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | LEOPOLD | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 932925 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 311932925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003649216 | ||||||||
| FaxNumber: | 4238925838 | ||||||||
| Practice Location | |||||||||
| Address1: | 303 PARKWAY DRIVE, NE | ||||||||
| Address2: | PMB 404 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303121212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4042654520 | ||||||||
| FaxNumber: | 4042653894 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2006 | ||||||||
| LastUpdateDate: | 12/20/2010 | ||||||||
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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 | 207L00000X | 047224 | GA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 1881631984 | 01 | GA | NPI | OTHER | 587007 | 01 | GA | BCBSGA (NSC) | OTHER | P00251519 | 01 | RAILROAD MEDICARE | OTHER | 000824216M | 05 | GA | MEDICAID | 000824216L | 05 | GA | MEDICAID | 858272 | 01 | GA | BCBSGA (AMC) | OTHER | 300966 | 01 | GA | WELLCARE MEDICAID | OTHER | 1982637419 | 01 | GA | GROUP NPI | OTHER |