Provider Demographics
NPI:1972842318
Name:JENKINS, RICHARD GORDON (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:GORDON
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 1:4767 OCEAN BLVD
Mailing Address - Street 2:501
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92109-2460
Mailing Address - Country:US
Mailing Address - Phone:858-750-2700
Mailing Address - Fax:
Practice Address - Street 1:4767 OCEAN BLVD
Practice Address - Street 2:501
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92109-2460
Practice Address - Country:US
Practice Address - Phone:858-750-2700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-05
Last Update Date:2013-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACFE43146OtherLICENSE CALIFORNIA