Provider Demographics
NPI:1609033182
Name:JACKSON, GAVIN N (MD)
Entity type:Individual
Prefix:DR
First Name:GAVIN
Middle Name:N
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4077 5TH AVE
Mailing Address - Street 2:MER35
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-2105
Mailing Address - Country:US
Mailing Address - Phone:619-260-7122
Mailing Address - Fax:619-260-7305
Practice Address - Street 1:4077 5TH AVE
Practice Address - Street 2:MER35
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2105
Practice Address - Country:US
Practice Address - Phone:619-260-7122
Practice Address - Fax:619-260-7305
Is Sole Proprietor?:No
Enumeration Date:2008-05-21
Last Update Date:2015-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA110647207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism