Provider Demographics
NPI:1235136052
Name:JENSEN, ERIC E (MD)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:E
Last Name:JENSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1107 MEMORIAL DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30720-8662
Mailing Address - Country:US
Mailing Address - Phone:706-226-3139
Mailing Address - Fax:706-278-6606
Practice Address - Street 1:1107 MEMORIAL DR
Practice Address - Street 2:SUITE 300
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720-8662
Practice Address - Country:US
Practice Address - Phone:706-226-3139
Practice Address - Fax:706-278-6606
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2013-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA50304207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000913393AMedicaid
GA11BDTKHMedicare ID - Type Unspecified
GA000913393AMedicaid