Provider Demographics
NPI:1124018395
Name:WATKINS, GORDON ELLIOTT (DPH)
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:ELLIOTT
Last Name:WATKINS
Suffix:
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1313 JAMESTOWN DR
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-6635
Mailing Address - Country:US
Mailing Address - Phone:918-456-0260
Mailing Address - Fax:918-456-9515
Practice Address - Street 1:RT 2, HWY 51 EAST
Practice Address - Street 2:
Practice Address - City:STILWELL
Practice Address - State:OK
Practice Address - Zip Code:74960
Practice Address - Country:US
Practice Address - Phone:918-696-8818
Practice Address - Fax:918-696-8881
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK11303183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist