Basic Information
| Provider Information | |||||||||
| NPI: | 1922049295 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | MELVIN | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2550 NORTH HOLLYWOOD WAY | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | BURBANK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 915055040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8185570135 | ||||||||
| FaxNumber: | 8185571394 | ||||||||
| Practice Location | |||||||||
| Address1: | 1225 WILSHIRE BOULEVARD | ||||||||
| Address2: | GOOD SAMARITAN HOSPITAL | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900172395 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2139772423 | ||||||||
| FaxNumber: | 2132027028 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2006 | ||||||||
| LastUpdateDate: | 02/27/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | G32876 | CA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | 207R00000X | G32876 | CA | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | G32876 | 01 | CA | BLUE CROSS | OTHER | 00G328760 | 01 | BLUE SHIELD | OTHER | 00G328760 | 05 | CA | MEDICAID |