Basic Information
| Provider Information | |||||||||
| NPI: | 1760878144 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JENKINS | ||||||||
| FirstName: | RANDOLPH | ||||||||
| MiddleName: | MITCHELL | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 95 MEDICAL PARK BLVD | ||||||||
| Address2: | |||||||||
| City: | PETERSBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 238059280 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8045048100 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 95 MEDICAL PARK BLVD | ||||||||
| Address2: | |||||||||
| City: | PETERSBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 238059280 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8045048100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2015 | ||||||||
| LastUpdateDate: | 05/18/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 0101261201 | VA | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
No ID Information.