Provider Demographics
NPI:1316065758
Name:JENKINS, MARK R II
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:R
Last Name:JENKINS
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1415 TULANE AVE
Mailing Address - Street 2:HC 71
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70112-2600
Mailing Address - Country:US
Mailing Address - Phone:504-988-5800
Mailing Address - Fax:
Practice Address - Street 1:1415 TULANE AVE
Practice Address - Street 2:HC 71
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70112-2600
Practice Address - Country:US
Practice Address - Phone:504-988-5800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2007-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC304622085R0202X
LAMD.0099802085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08238561Medicaid
LA1012947Medicaid
P00417482OtherRAILROAD MEDICARE
LA4K544CV55Medicare PIN
P00417482OtherRAILROAD MEDICARE