1679837785 NPI number — G. MARK JENKINS, MD PA

Table of content: (NPI 1679837785)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679837785 NPI number — G. MARK JENKINS, MD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
G. MARK JENKINS, MD PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1679837785
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/25/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
950 SCOTLAND DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DESOTO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75115-2057
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-352-8838
Provider Business Mailing Address Fax Number:
214-946-7445

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
221 W COLORADO BLVD STE 933
Provider Second Line Business Practice Location Address:
STE 933
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75208-2362
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-946-9898
Provider Business Practice Location Address Fax Number:
214-946-7445
Provider Enumeration Date:
07/03/2012

Additional Information

Authorized Official

Authorized Official Last Name:
JENKINS
Authorized Official First Name:
GEORGE
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
972-352-8838

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X , with the licence number:  K6614 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0057XZ . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 311312801 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com