Provider Demographics
NPI:1104812874
Name:JENKINSON, DAVID M (DO)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:M
Last Name:JENKINSON
Suffix:
Gender:M
Credentials:DO
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 896239
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28289-6239
Mailing Address - Country:US
Mailing Address - Phone:803-568-2000
Mailing Address - Fax:
Practice Address - Street 1:935 W 2ND ST
Practice Address - Street 2:
Practice Address - City:SWANSEA
Practice Address - State:SC
Practice Address - Zip Code:29160-8665
Practice Address - Country:US
Practice Address - Phone:803-568-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-27
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1487207QS0010X
SC35705207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC357055Medicaid
F83213Medicare UPIN
SC357055Medicaid