Provider Demographics
NPI:1619397775
Name:TERRI SUSANNE JONES WATKINS ODPSC
Entity Type:Organization
Organization Name:TERRI SUSANNE JONES WATKINS ODPSC
Other - Org Name:WATKINS VISION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TERRI
Authorized Official - Middle Name:SUSANNE
Authorized Official - Last Name:JONES WATKINS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:270-866-3177
Mailing Address - Street 1:PO BOX 582
Mailing Address - Street 2:
Mailing Address - City:RUSSELL SPRINGS
Mailing Address - State:KY
Mailing Address - Zip Code:42642-0582
Mailing Address - Country:US
Mailing Address - Phone:270-866-3177
Mailing Address - Fax:270-866-3155
Practice Address - Street 1:24 CADEN WAY, SUITE 2
Practice Address - Street 2:
Practice Address - City:RUSSELL SPRINGS
Practice Address - State:KY
Practice Address - Zip Code:42642
Practice Address - Country:US
Practice Address - Phone:270-866-3177
Practice Address - Fax:270-866-3155
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-16
Last Update Date:2014-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1235DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77012359Medicaid
U34561Medicare UPIN
9331901Medicare PIN