Provider Demographics
NPI:1154470318
Name:JENKINS, WAYNE D (OD)
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:D
Last Name:JENKINS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 WESTFARMS MALL # D111
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06032-2631
Mailing Address - Country:US
Mailing Address - Phone:860-561-5687
Mailing Address - Fax:860-561-8905
Practice Address - Street 1:61 WESTFARMS MALL # D111
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06032-2631
Practice Address - Country:US
Practice Address - Phone:860-561-5687
Practice Address - Fax:860-561-8905
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTCT2074152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTU05378Medicare UPIN
CTC01275Medicare ID - Type Unspecified