Basic Information
| Provider Information | |||||||||
| NPI: | 1164588448 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | BENJAMIN | ||||||||
| MiddleName: | MATERI | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3400 SPRUCE STREET | ||||||||
| Address2: | 4 SILVERSTEIN BUILDING | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191044206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2156154949 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1259 S CEDAR CREST BLVD STE 301 | ||||||||
| Address2: | |||||||||
| City: | ALLENTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 181036206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6104029400 | ||||||||
| FaxNumber: | 6104378807 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2006 | ||||||||
| LastUpdateDate: | 07/18/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | MD420325 | PA | N | Allopathic & Osteopathic Physicians | Surgery | 2086S0129X | MT047810T | PA | N | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 2086S0129X | MD420325 | PA | Y | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
No ID Information.