Provider Demographics
NPI:1730276163
Name:JENKINS, KEVIN M (DO)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:M
Last Name:JENKINS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:944 W FOOTHILL BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-3757
Mailing Address - Country:US
Mailing Address - Phone:909-985-2874
Mailing Address - Fax:909-949-8314
Practice Address - Street 1:944B W FOOTHILL BLVD STE B
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-3728
Practice Address - Country:US
Practice Address - Phone:909-985-2874
Practice Address - Fax:909-949-8314
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2015-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A4451207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA020A44510Medicaid
CA020A44510Medicaid
C64519Medicare ID - Type Unspecified