Provider Demographics
NPI:1669613907
Name:JENKINS, DEREK RANDALL (MD)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:RANDALL
Last Name:JENKINS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1119
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02901-1119
Mailing Address - Country:US
Mailing Address - Phone:401-453-9032
Mailing Address - Fax:401-861-5812
Practice Address - Street 1:1 KETTLE POINT AVE
Practice Address - Street 2:
Practice Address - City:EAST PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02914-5375
Practice Address - Country:US
Practice Address - Phone:401-453-9032
Practice Address - Fax:401-861-5812
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-17
Last Update Date:2019-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN106300207X00000X
MN55660207X00000X
NH16277207XS0114X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNENROLLEDMedicaid
IAENROLLEDMedicaid
MNENROLLEDMedicaid