Provider Demographics
NPI:1447431275
Name:WATKINS, JEREMIAH RAY (MD)
Entity Type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:RAY
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 1:1968 PEACHTREE RD NW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-1281
Mailing Address - Country:US
Mailing Address - Phone:404-605-2054
Mailing Address - Fax:404-609-6766
Practice Address - Street 1:5301 VIRGINIA WAY
Practice Address - Street 2:SUITE 300
Practice Address - City:BRENTWOOD
Practice Address - State:TN
Practice Address - Zip Code:37027-7541
Practice Address - Country:US
Practice Address - Phone:615-221-4474
Practice Address - Fax:615-234-3774
Is Sole Proprietor?:No
Enumeration Date:2007-11-20
Last Update Date:2014-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA059231207ZP0105X
GA59231207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003126490CMedicaid
GA059231OtherSTATE LICENCSE
GA003126490DMedicaid