Healthcare Provider Details

I. General information

NPI: 1619934213
Provider Name (Legal Business Name): RANDALL D. JENKINS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2006
Last Update Date: 01/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E IDAHO ST SUITE 304
BOISE ID
83712
US

IV. Provider business mailing address

190 E BANNOCK ST
BOISE ID
83712-6241
US

V. Phone/Fax

Practice location:
  • Phone: 208-381-7336
  • Fax: 208-381-7029
Mailing address:
  • Phone: 208-706-8449
  • Fax: 208-381-7029

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0210X
TaxonomyPediatric Nephrology Physician
License Number12771
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code2080P0210X
TaxonomyPediatric Nephrology Physician
License NumberM-6953
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: