Basic Information
| Provider Information | |||||||||
| NPI: | 1942206453 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | DEWITT | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1267 | ||||||||
| Address2: | |||||||||
| City: | MT AIRY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 270301267 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367864522 | ||||||||
| FaxNumber: | 3367893025 | ||||||||
| Practice Location | |||||||||
| Address1: | 708 S SOUTH ST | ||||||||
| Address2: | STE 100 | ||||||||
| City: | MT AIRY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 270304426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367899176 | ||||||||
| FaxNumber: | 3367863778 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2005 | ||||||||
| LastUpdateDate: | 10/29/2015 | ||||||||
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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 | 208600000X | 18662 | NC | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1912995093 | 01 | NC | SURRY SURGICAL GROUP NPI | OTHER | 8945509 | 05 | NC | MEDICAID |