Basic Information
| Provider Information | |||||||||
| NPI: | 1891796900 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | SPENCER | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 7580 BUCKINGHAM BLVD STE 220 | ||||||||
| Address2: | |||||||||
| City: | HANOVER | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210763210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107295100 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 11055 LITTLE PATUXENT PKWY | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | COLUMBIA | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210442896 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107400789 | ||||||||
| FaxNumber: | 4107407024 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2005 | ||||||||
| LastUpdateDate: | 08/22/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | D35217 | MD | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 398140-03 | 01 | MD | CAREFIRST MD RENDERING | OTHER | 4238639 | 01 | MD | AETNA FEE FOR SERVICE | OTHER | P528953 | 01 | MD | CAREFIRST MPOS | OTHER | 0477972 | 01 | MD | AETNA CAPITATED | OTHER | 478471500 | 05 | MD | MEDICAID | 060041579 | 01 | MD | RR MEDICARE | OTHER | 318934 | 01 | MD | MAMSI SPECIALIST | OTHER | 3509-0006 | 01 | MD | CAREFIRST BLUECHOICE | OTHER | 018410 | 01 | MD | JHHC PROVIDER NUMBER | OTHER | 0149212 | 01 | MD | CIGNA PIN | OTHER |