Provider Demographics
NPI:1568433035
Name:WATKIN, DAVID A (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:A
Last Name:WATKIN
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 1:111 17TH AVE E
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:MN
Mailing Address - Zip Code:56308-5273
Mailing Address - Country:US
Mailing Address - Phone:320-762-1511
Mailing Address - Fax:
Practice Address - Street 1:1527 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:MN
Practice Address - Zip Code:56308-2537
Practice Address - Country:US
Practice Address - Phone:320-762-0399
Practice Address - Fax:320-762-6847
Is Sole Proprietor?:No
Enumeration Date:2006-01-31
Last Update Date:2017-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN37057174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN080059753OtherRR MEDICARE
MN436527500Medicaid
MN01-16047OtherPHP-ID
MNHP24048OtherHEALTHPARTNERS
MN089000136OtherMET
MN5T550WAOtherBC/BS
MN5T550WAOtherBC/BS