Provider Demographics
NPI:1700987062
Name:JACKSON, ANTHONY W SR (MD)
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:W
Last Name:JACKSON
Suffix:SR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27909-3361
Mailing Address - Country:US
Mailing Address - Phone:252-337-7409
Mailing Address - Fax:252-337-7410
Practice Address - Street 1:105 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909-3361
Practice Address - Country:US
Practice Address - Phone:252-337-7409
Practice Address - Fax:252-337-7410
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2011-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2007-00605207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC14516OtherBCBSNC
NC5906945Medicaid