Provider Demographics
NPI:1629069778
Name:WATKIN, DOVE D (MD)
Entity Type:Individual
Prefix:
First Name:DOVE
Middle Name:D
Last Name:WATKIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 CENTRACARE CIR
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-5000
Mailing Address - Country:US
Mailing Address - Phone:320-654-3630
Mailing Address - Fax:320-654-3657
Practice Address - Street 1:1900 CENTRACARE CIR
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-5000
Practice Address - Country:US
Practice Address - Phone:320-654-3630
Practice Address - Fax:320-654-3657
Is Sole Proprietor?:No
Enumeration Date:2005-10-28
Last Update Date:2011-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN37923208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
1027103OtherPREFERRED ONE
COMPOtherCHAMPUS
151800OtherU CARE
40F76WAOtherBLUE CROSS BLUE SHIELD
3900974OtherARAZ GROUP AMERICAS PPO
COMPOtherMMSI
COMPOtherONE HEALTH PLAN GREAT WES
1256322OtherMEDICA HEALTH PLANS
MN575522100Medicaid
HP23202OtherHEALTH PARTNERS
2129266OtherFIRST HEALTH PLAN
COMPOtherONE HEALTH PLAN GREAT WES
MN575522100Medicaid