Provider Demographics
NPI:1316005895
Name:JENKINS, MARY DALE (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:DALE
Last Name:JENKINS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:366 N BROADWAY
Mailing Address - Street 2:SUITE 305
Mailing Address - City:JERICHO
Mailing Address - State:NY
Mailing Address - Zip Code:11753-2025
Mailing Address - Country:US
Mailing Address - Phone:516-935-7272
Mailing Address - Fax:516-935-7282
Practice Address - Street 1:366 N BROADWAY
Practice Address - Street 2:SUITE 305
Practice Address - City:JERICHO
Practice Address - State:NY
Practice Address - Zip Code:11753-2025
Practice Address - Country:US
Practice Address - Phone:516-935-7272
Practice Address - Fax:516-935-7282
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY154307207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
14D991Medicare PIN
NYA60702Medicare UPIN