Organization
KEITH RYAN JACKSON MD PC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. KEITH RYAN JACKSON M.D. (PRESIDENT)
(718) 727-1331
Entity
Organization
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
02/19/2008
Last updated
05/29/2013
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