Provider Demographics
NPI:1407420490
Name:WATKINS, MICHAEL T
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:T
Last Name:WATKINS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6225 SMITH AVE STE 1001A
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21209-3626
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:22 BOWERS ST APT 610
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01854-3581
Practice Address - Country:US
Practice Address - Phone:978-771-5575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-14
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA201574175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA201574OtherTRANSFORMATION CENTER BOSTON
MA201574Medicaid