Basic Information
| Provider Information | |||||||||
| NPI: | 1932143435 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JENKINS | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1605 W FAIRBANKS AVE | ||||||||
| Address2: | |||||||||
| City: | WINTER PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327894603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4079750200 | ||||||||
| FaxNumber: | 4079750209 | ||||||||
| Practice Location | |||||||||
| Address1: | 1605 W FAIRBANKS AVE | ||||||||
| Address2: | |||||||||
| City: | WINTER PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327894603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4079750200 | ||||||||
| FaxNumber: | 4079750209 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2006 | ||||||||
| LastUpdateDate: | 05/10/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | ME77991 | FL | Y | Allopathic & Osteopathic Physicians | Neurological Surgery |
ID Information
| ID | Type | State | Issuer | Description | 256147600 | 05 | FL | MEDICAID | 46560 | 01 | FL | BCBS | OTHER | P00003494 | 01 | RAILROAD MEDICARE | OTHER |