Provider Demographics
NPI:1245411727
Name:HARVEY C JENKINS PH D M D PLLC
Entity Type:Organization
Organization Name:HARVEY C JENKINS PH D M D PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:TASHONDA
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:DIXON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-686-1700
Mailing Address - Street 1:8603 S WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73139-9200
Mailing Address - Country:US
Mailing Address - Phone:405-686-1700
Mailing Address - Fax:405-686-1555
Practice Address - Street 1:8603 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73139-9200
Practice Address - Country:US
Practice Address - Phone:405-686-1700
Practice Address - Fax:405-686-1555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-26
Last Update Date:2012-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK21473174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100034590AMedicaid
OK37D1102406OtherCLIA LABORATORY
OK=========001OtherBC/BS OF OKLAHOMA
OK=========001OtherBC/BS OF OKLAHOMA
OK100034590AMedicaid