Provider Demographics
NPI:1700818697
Name:JENSEN, ERIC RICHARD (MD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:RICHARD
Last Name:JENSEN
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 1:100 EAST MAIN ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501-6041
Mailing Address - Country:US
Mailing Address - Phone:541-789-7000
Mailing Address - Fax:
Practice Address - Street 1:2825 E. BARNETT RD
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-8332
Practice Address - Country:US
Practice Address - Phone:541-789-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2009-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD23858207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR286331Medicaid
ORH35590Medicare UPIN
OR139346Medicare PIN
H35590Medicare UPIN
OR286331Medicaid