Provider Demographics
NPI:1588653190
Name:JENKINS, ERIC D (MD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:D
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 1:173 HOLLYWOOD ST
Mailing Address - Street 2:
Mailing Address - City:OBERLIN
Mailing Address - State:OH
Mailing Address - Zip Code:44074-1009
Mailing Address - Country:US
Mailing Address - Phone:440-774-6929
Mailing Address - Fax:
Practice Address - Street 1:200 W LORAIN ST
Practice Address - Street 2:
Practice Address - City:OBERLIN
Practice Address - State:OH
Practice Address - Zip Code:44074-1026
Practice Address - Country:US
Practice Address - Phone:440-775-1211
Practice Address - Fax:440-774-5707
Is Sole Proprietor?:No
Enumeration Date:2005-10-17
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35078673207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2547793Medicaid
OH000000518261OtherBCBS
P00406924OtherRAILROAD
I26094Medicare UPIN
OH2547793Medicaid
OHJE4153072Medicare PIN