Keith Ryan Jackson MD PC

Primary specialty

Dermatology PhysicianTaxonomy code 207N00000X

License

212165 Issued in NY

Legal business name

KEITH RYAN JACKSON MD PC

Practice address

11 Ralph PL
Suite 209
Staten Island, NY 10304-4419

Phone

(718) 727-1331

Fax

(718) 727-2159

NPI assigned

Feb 19, 2008

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Dr. Keith Ryan Jackson, M.D.NPI 1124116041

Title

President

Phone

(718) 727-1331

Specialties & licenses 1

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Enrolled in NY

Enrollment records 1

Locations

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Keith Ryan Jackson, M.D.

  • Dermatology Physician
  • Staten Island, NY
  • NPI 1124116041
  Medicare reassignment NPD Authorized official
• Elena Sapon, NP

  • Family Nurse Practitioner
  • Staten Island, NY
  • NPI 1851182893

  Dermatology

  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1203379200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1369785600000",
    "number": "1326216847",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "11 RALPH PL",
            "address_2": "SUITE 209",
            "city": "STATEN ISLAND",
            "state": "NY",
            "postal_code": "103044419",
            "telephone_number": "718-727-1331",
            "fax_number": "718-727-2159"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "11 RALPH PL",
            "address_2": "SUITE 209",
            "city": "STATEN ISLAND",
            "state": "NY",
            "postal_code": "103044419",
            "telephone_number": "718-727-1331",
            "fax_number": "718-727-2159"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "KEITH RYAN JACKSON MD PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-02-19",
        "last_updated": "2013-05-29",
        "status": "A",
        "authorized_official_last_name": "JACKSON",
        "authorized_official_first_name": "KEITH",
        "authorized_official_middle_name": "RYAN",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "718-727-1331",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "207N00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dermatology",
            "state": "NY",
            "license": "212165",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "02239307",
            "state": "NY"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Wanda Kehoe, BS/ OTR/L
• Maduyen Keita
• Tina Keita, RN
• Keith a Mobilia & Janet Carney DPM PC
• Keith a Mobilia,DPM.PC
• Rhonda Kelleher Nigido
• Alexandra E Kelleher, MA, OTR/L
• Rachel Marni Kellner, LMSW
• Jazmine Kelly-Bolton, LMSW
• Alexandra Kelly

• Dermatology Physician in Staten Island, NY
• Providers in Staten Island, NY by specialty
• Dermatology Physician in New York

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 29, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.