Provider Demographics
NPI:1013145853
Name:JENKINS-MOSURE, KRISTAN GAIL (MD)
Entity Type:Individual
Prefix:
First Name:KRISTAN
Middle Name:GAIL
Last Name:JENKINS-MOSURE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KRISTAN
Other - Middle Name:GAIL
Other - Last Name:JENKINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2213 CHERRY ST
Mailing Address - Street 2:ATTN: MRG ASSOCIATES, LLC - RADIOLOGY DEPT.
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43608-2603
Mailing Address - Country:US
Mailing Address - Phone:419-251-2740
Mailing Address - Fax:
Practice Address - Street 1:2799 W GRAND BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-2608
Practice Address - Country:US
Practice Address - Phone:800-653-6568
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-01
Last Update Date:2022-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010885722085B0100X, 2085R0202X
OH350989782085B0100X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH35098978OtherOH MEDICAL LICENSE
OH0067438Medicaid
OH35098978OtherOH MEDICAL LICENSE