Provider Demographics
NPI:1982627212
Name:JENKINS, ROGER C (OD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:C
Last Name:JENKINS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 290
Mailing Address - Street 2:12 S DIVISION STREET
Mailing Address - City:DU QUOIN
Mailing Address - State:IL
Mailing Address - Zip Code:62832-0290
Mailing Address - Country:US
Mailing Address - Phone:618-542-2157
Mailing Address - Fax:618-542-6388
Practice Address - Street 1:12 S DIVISION ST
Practice Address - Street 2:
Practice Address - City:DU QUOIN
Practice Address - State:IL
Practice Address - Zip Code:62832-1302
Practice Address - Country:US
Practice Address - Phone:618-542-2157
Practice Address - Fax:618-542-6388
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL04600627152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0416560001OtherRR MEDICARE
IL046006277Medicaid
IL296540Medicare PIN
IL0416560001OtherRR MEDICARE
IL046006277Medicaid