Healthcare Provider Details

I. General information

NPI: 1205271137
Provider Name (Legal Business Name): ELAN JENKINS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/06/2013
Last Update Date: 08/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 DOWMAN DR NE
ATLANTA GA
30322-1007
US

IV. Provider business mailing address

660 RALPH MCGILL BLVD NE APT 1410
ATLANTA GA
30312-1149
US

V. Phone/Fax

Practice location:
  • Phone: 404-727-6123
  • Fax:
Mailing address:
  • Phone: 575-779-0124
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number1205271137
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: