Provider Demographics
NPI:1619934213
Name:JENKINS, RANDALL D (MD)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
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 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-706-8449
Mailing Address - Fax:208-381-7029
Practice Address - Street 1:100 E IDAHO ST
Practice Address - Street 2:SUITE 304
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712
Practice Address - Country:US
Practice Address - Phone:208-381-7336
Practice Address - Fax:208-381-7029
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2016-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR127712080P0210X
IDM-69532080P0210X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0210XAllopathic & Osteopathic PhysiciansPediatricsPediatric Nephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID00340150Medicaid
OR270819Medicaid
WA8518003Medicaid
CAXPY 190107Medicaid
ALMD7720RMedicaid
ID20000416Medicare PIN
OR00WFBRHAMedicare ID - Type UnspecifiedOREGON MEDICARE INDIVIDUA
CAXPY 190107Medicaid
OR270819Medicaid