Provider Demographics
NPI:1437291713
Name:JENKINS, BENJAMIN LARRY JR (MD)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:LARRY
Last Name:JENKINS
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 2665
Mailing Address - Street 2:
Mailing Address - City:LA PLATA
Mailing Address - State:MD
Mailing Address - Zip Code:20646-2665
Mailing Address - Country:US
Mailing Address - Phone:301-934-2887
Mailing Address - Fax:301-392-1133
Practice Address - Street 1:111 LAGRANGE AVE.
Practice Address - Street 2:
Practice Address - City:LAPLATA
Practice Address - State:MD
Practice Address - Zip Code:20624
Practice Address - Country:US
Practice Address - Phone:301-934-2887
Practice Address - Fax:301-392-1133
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2010-10-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDD0033426207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD4493Medicare PIN