Provider Demographics
NPI:1487829347
Name:JERKINS, BRIAN MONTGOMERY (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:MONTGOMERY
Last Name:JERKINS
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 1:1407 UNION AVE STE 700
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-3641
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:930 MADISON AVE STE 200
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38163
Practice Address - Country:US
Practice Address - Phone:901-448-6650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-22
Last Update Date:2018-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.205311207W00000X
TN49786207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2195697Medicaid
MS02959848Medicaid
AR198406001Medicaid
TNQ002086Medicaid
MO1487829347Medicaid