Provider Demographics
NPI:1659396695
Name:WATKINS, JOSEPH R (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:R
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 1:1055 N 300 W STE 404
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3359
Mailing Address - Country:US
Mailing Address - Phone:801-357-7401
Mailing Address - Fax:801-357-3708
Practice Address - Street 1:1055 N 300 W STE 404
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-3359
Practice Address - Country:US
Practice Address - Phone:801-357-7401
Practice Address - Fax:801-357-3708
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2013-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT17066512052084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY7246AOtherWYOMING LICENSE
WYW21096Medicare PIN
UT005772201Medicare PIN