Provider records sourced from NPPES (CMS National Plan & Provider Enumeration System). Data current as of August 10, 2026.
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Dr. Keith Ryan Jackson, MD

Individual provider Dermatology Physician · NPI 1124116041

Dr. Keith Ryan Jackson, MD is a Dermatology in Staten Island, New York. Graduated from State University of New York Downstate Medical Center in 1997, 29 years ago. Practices as a sole proprietor. Licensed in New York.

Years since qualifying
29
Trained at
State University of New York Downstate Medical Center
Licensed in
NY
In the registry since
2006
What do these letters mean?
MD — Doctor of Medicine
A physician who completed allopathic medical school.

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Practice location Address checks out

11 Ralph Pl Ste 209
Staten Island, NY 10304-4419
Phone: (718) 727-1331
Fax: (718) 727-2159
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Pin is approximate — placed at the ZIP-code centre, not the exact door.

Specialties & licences

Dermatology Physician (primary) Taxonomy 207N00000X · Licence 212165 (NY)

Record details

NPI number1124116041
Entity typeIndividual (Type 1)
GenderMale
Credentials MD
Sole proprietorYes
NPI enumeratedOctober 10, 2006
Last updated in NPPESMay 28, 2013

Medicare enrollment

From the CMS Doctors & Clinicians file — this clinician is enrolled in Medicare.

Medicare specialtyDERMATOLOGY
Medical schoolSTATE UNIVERSITY OF NEW YORK DOWNSTATE MEDICAL CENTER
Graduated 1997 (29 years in practice)
Accepts Medicare assignment Not indicated

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