Individual
RANDOLPH THOMAS JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
11010 HASKELL AVE, KANSAS CITY, KS 66109-8500
(816) 478-1230
(816) 350-4166
Mailing address
4801 S CLIFF AVE, SUITE 100, INDEPENDENCE, MO 64055-7015
(816) 350-4536
(816) 350-4585
Taxonomy
Speciality
Code
Description
License number
State
207W00000X
Ophthalmology Physician
10506
MT
207W00000X
Ophthalmology Physician
2006012805
MO
207W00000X
Ophthalmology Physician
Primary
31896
KS
207W00000X
Ophthalmology Physician
46566
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
P00685107
RAILROAD MEDICARE
KS
Enumeration date
03/18/2006
Last updated
05/07/2009
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