Provider Demographics
NPI:1487654653
Name:JENKINS, WALLACE RUSSELL (MD)
Entity Type:Individual
Prefix:
First Name:WALLACE
Middle Name:RUSSELL
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 1:503 GRASSLANDS RD
Mailing Address - Street 2:STE 200
Mailing Address - City:VALHALLA
Mailing Address - State:NY
Mailing Address - Zip Code:10595-1503
Mailing Address - Country:US
Mailing Address - Phone:914-304-5288
Mailing Address - Fax:914-345-1755
Practice Address - Street 1:503 GRASSLANDS RD
Practice Address - Street 2:STE 200
Practice Address - City:VALHALLA
Practice Address - State:NY
Practice Address - Zip Code:10595
Practice Address - Country:US
Practice Address - Phone:914-304-5288
Practice Address - Fax:914-345-1755
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2013-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1838002080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01210104Medicaid
NY94F871Medicare PIN
NY01210104Medicaid
NYE95140Medicare UPIN
NY94F87EA201Medicare PIN