Provider Demographics
NPI:1528161817
Name:JINKS, DERMOT CONNOLE (DC)
Entity type:Individual
Prefix:DR
First Name:DERMOT
Middle Name:CONNOLE
Last Name:JINKS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 ROWLAND ST
Mailing Address - Street 2:
Mailing Address - City:BALLSTON SPA
Mailing Address - State:NY
Mailing Address - Zip Code:12020-2684
Mailing Address - Country:US
Mailing Address - Phone:518-363-0202
Mailing Address - Fax:518-363-0711
Practice Address - Street 1:49 CENTRAL ST
Practice Address - Street 2:SUITE 1A
Practice Address - City:PEABODY
Practice Address - State:MA
Practice Address - Zip Code:01960-4375
Practice Address - Country:US
Practice Address - Phone:978-531-0202
Practice Address - Fax:978-532-7076
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-05
Last Update Date:2016-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX011848193400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes193400000XGroupSingle Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY36302OtherBLUE CROSS BLUE SHIELD #
MAY45296Medicare ID - Type UnspecifiedPROVIDER ID #