Provider Demographics
NPI:1083604714
Name:WATKINS, LARRY E (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:E
Last Name:WATKINS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:301 E MAUMEE ST STE 201
Practice Address - Street 2:
Practice Address - City:ANGOLA
Practice Address - State:IN
Practice Address - Zip Code:46703-2012
Practice Address - Country:US
Practice Address - Phone:260-665-2164
Practice Address - Fax:260-665-3932
Is Sole Proprietor?:No
Enumeration Date:2005-10-25
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01025697207Q00000X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000226066OtherANTHEM ID FOR ANESTHESIA
IN100329360Medicaid
IN000000088994OtherANTHEM ID FOR GEN PRACTIC
IN000000697433OtherANTHEM
IN000000697433OtherANTHEM
IN771300BMedicare ID - Type Unspecified
INC25609Medicare UPIN
INM400037704Medicare PIN
771300Medicare PIN