Provider Demographics
NPI:1932211380
Name:JENNINGS, ROBERT STEPHEN (MD, FAAFP)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:STEPHEN
Last Name:JENNINGS
Suffix:
Gender:M
Credentials:MD, FAAFP
Other - Prefix:DR
Other - First Name:R STEPHEN
Other - Middle Name:
Other - Last Name:JENNINGS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD, FAAFP
Mailing Address - Street 1:22 ODYSSEY STE 110
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-3186
Mailing Address - Country:US
Mailing Address - Phone:949-717-4811
Mailing Address - Fax:949-717-4810
Practice Address - Street 1:22 ODYSSEY STE 110
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618-3186
Practice Address - Country:US
Practice Address - Phone:949-717-4811
Practice Address - Fax:949-717-4810
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA35456207QA0000X, 207QA0505X, 207QB0002X, 207QS0010X, 207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
No207QA0000XAllopathic & Osteopathic PhysiciansFamily MedicineAdolescent Medicine
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
No207QB0002XAllopathic & Osteopathic PhysiciansFamily MedicineObesity Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA27794Medicare UPIN