Basic Information
| Provider Information | |||||||||
| NPI: | 1669613907 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JENKINS | ||||||||
| FirstName: | DEREK | ||||||||
| MiddleName: | RANDALL | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1119 | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029011119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014539032 | ||||||||
| FaxNumber: | 4018615812 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 KETTLE POINT AVE | ||||||||
| Address2: | |||||||||
| City: | EAST PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029145375 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014539032 | ||||||||
| FaxNumber: | 4018615812 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2009 | ||||||||
| LastUpdateDate: | 02/12/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 106300 | MN | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | 55660 | MN | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XS0114X | 16277 | NH | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Adult Reconstructive Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | ENROLLED | 05 | MN | MEDICAID | ENROLLED | 05 | IA | MEDICAID |