Provider Demographics
NPI:1417927518
Name:JENKINS, WALTER THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:THOMAS
Last Name:JENKINS
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:PO BOX 658
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30503-0658
Mailing Address - Country:US
Mailing Address - Phone:770-718-1122
Mailing Address - Fax:770-535-7445
Practice Address - Street 1:725 JESSE JEWELL PKWY SE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3834
Practice Address - Country:US
Practice Address - Phone:770-297-2200
Practice Address - Fax:770-534-8139
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2011-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA015385207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000153777CMedicaid
GA10050576OtherAMERIGROUP
GA0700332OtherUNITED HEALTHCARE
GA160029720OtherRR MEDICARE-GRP # CC4177
GA1619821OtherCIGNA
GA000153777HMedicaid
GA000153777IMedicaid
GA340855OtherWELLCARE
GA52348753OtherBCBS
GA0700332OtherUNITED HEALTHCARE
GA16BDFCPMedicare ID - Type Unspecified