Provider Demographics
NPI:1902869126
Name:JACKSON, ROBERT K (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:K
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 908
Mailing Address - Street 2:
Mailing Address - City:MCALESTER
Mailing Address - State:OK
Mailing Address - Zip Code:74502-0908
Mailing Address - Country:US
Mailing Address - Phone:918-426-0240
Mailing Address - Fax:918-423-4051
Practice Address - Street 1:1401 E VAN BUREN AVE
Practice Address - Street 2:
Practice Address - City:MCALESTER
Practice Address - State:OK
Practice Address - Zip Code:74501-4245
Practice Address - Country:US
Practice Address - Phone:918-426-0240
Practice Address - Fax:918-423-4051
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK10090207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK731310891006OtherUNICARE
OK1324230001OtherPALMETTO DME
OK74502A013OtherCHAMPUS (WPS)
OK0166707OtherUMWA
OK731310891028OtherTRICARE SOUTH
OKE11363OtherSTERLING OPTION 1
OK731310891028OtherTRICARE SOUTH