Provider Demographics
NPI:1174554521
Name:JACKSON, LANCE ELLIOT (MD, FACS)
Entity type:Individual
Prefix:DR
First Name:LANCE
Middle Name:ELLIOT
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD, FACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18518 HARDY OAK
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78258-4271
Mailing Address - Country:US
Mailing Address - Phone:210-696-4327
Mailing Address - Fax:210-798-2509
Practice Address - Street 1:18518 HARDY OAK
Practice Address - Street 2:SUITE 300
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258-4271
Practice Address - Country:US
Practice Address - Phone:210-696-4327
Practice Address - Fax:210-798-2509
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2013-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL5777174400000X, 207YX0901X, 207Y00000X, 207YX0602X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0901XAllopathic & Osteopathic PhysiciansOtolaryngologyOtology & Neurotology
No174400000XOther Service ProvidersSpecialist
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No207YX0602XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngic Allergy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP00019999OtherRAILROAD MEDICARE
TX157518501Medicaid
TX7047136OtherAETNA
TX8H5000OtherBLUE SHIELD
TXMDL5777OtherWORKERS COMP
TX157518501Medicaid
TXMDL5777OtherWORKERS COMP