Provider Demographics
NPI:1154488682
Name:LARRY P JENKINS MD PA
Entity Type:Organization
Organization Name:LARRY P JENKINS MD PA
Other - Org Name:STANLY COUNTY EYE CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:PARKER
Authorized Official - Last Name:JENKINS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-983-1102
Mailing Address - Street 1:923 N 2ND STREET
Mailing Address - Street 2:SUITE 103
Mailing Address - City:ALBEMARLE
Mailing Address - State:NC
Mailing Address - Zip Code:28001-3367
Mailing Address - Country:US
Mailing Address - Phone:704-983-1102
Mailing Address - Fax:704-983-2503
Practice Address - Street 1:923 N 2ND STREET
Practice Address - Street 2:SUITE 103
Practice Address - City:ALBEMARLE
Practice Address - State:NC
Practice Address - Zip Code:28001-3367
Practice Address - Country:US
Practice Address - Phone:704-983-1102
Practice Address - Fax:704-983-2503
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2008-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC17874207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0138190001OtherDMERC
NC45887OtherBLUE CROSS BLUE SHIELD
NC45887OtherBCBS NC
NC1356345169OtherNPI INDIVIDUAL
NC8945887Medicaid
NC45887OtherBCBS NC
NC8945887Medicaid
NCC80652Medicare UPIN
NC201401Medicare ID - Type Unspecified
NC0138190001Medicare NSC