Provider Demographics
NPI:1548292543
Name:JENKINS, C. MITCHELL (MD)
Entity type:Individual
Prefix:DR
First Name:C.
Middle Name:MITCHELL
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 51014
Mailing Address - Street 2:
Mailing Address - City:ELEELE
Mailing Address - State:HI
Mailing Address - Zip Code:96705-1014
Mailing Address - Country:US
Mailing Address - Phone:808-335-0579
Mailing Address - Fax:808-335-0581
Practice Address - Street 1:4469 WAIALO RD
Practice Address - Street 2:
Practice Address - City:ELEELE
Practice Address - State:HI
Practice Address - Zip Code:96705
Practice Address - Country:US
Practice Address - Phone:808-335-0579
Practice Address - Fax:808-335-0581
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD-7755207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI223743OtherHMA
HI542490OtherALOHACARE
HI54249001Medicaid
HI2688402OtherUHA
HIC47570OtherKAISER
HIC47570Medicare UPIN
HI55972Medicare ID - Type Unspecified