Individual
DR. KEITH RYAN JACKSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
11 RALPH PL, SUITE 209, STATEN ISLAND, NY 10304-4419
(718) 727-1331
(718) 727-2159
Mailing address
11 RALPH PL, SUITE 209, STATEN ISLAND, NY 10304-4419
(718) 727-1331
(718) 727-2159
Taxonomy
Speciality
Code
Description
License number
State
207N00000X
Dermatology Physician
Primary
212165
NY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
02239307
—
NY
Enumeration date
10/10/2006
Last updated
05/28/2013
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