Provider Demographics
NPI:1124023874
Name:WATKINS, GLEN LEE (MD)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:LEE
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 1:1000 CHINABERRY DR STE 1103
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-2463
Mailing Address - Country:US
Mailing Address - Phone:318-716-1111
Mailing Address - Fax:318-716-1112
Practice Address - Street 1:1000 CHINABERRY DR STE 1103
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-2463
Practice Address - Country:US
Practice Address - Phone:318-716-1111
Practice Address - Fax:318-716-1112
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-19
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME98502207Y00000X
GA050489207Y00000X
LA205062207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA21744801Medicaid
LA21744801Medicaid
GA00918992AMedicaid