Provider Demographics
NPI:1558310011
Name:JENKINS, TIMOTHY OWEN (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:OWEN
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 1:1701 EAST BLVD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203-5823
Mailing Address - Country:US
Mailing Address - Phone:704-334-7800
Mailing Address - Fax:704-414-7512
Practice Address - Street 1:1701 EAST BLVD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-5823
Practice Address - Country:US
Practice Address - Phone:704-334-7800
Practice Address - Fax:704-414-7512
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2015-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC323182085R0204X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7945886Medicaid
NC7945886Medicaid
300027974Medicare PIN
NC7945886Medicaid