Provider Demographics
NPI:1659926947
Name:WATKINS, MICHAEL JEROME
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JEROME
Last Name:WATKINS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6659 SCHAEFER RD STE 1073
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-1812
Mailing Address - Country:US
Mailing Address - Phone:313-403-3900
Mailing Address - Fax:313-731-1844
Practice Address - Street 1:19460 WHITCOMB ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235-2059
Practice Address - Country:US
Practice Address - Phone:313-953-1170
Practice Address - Fax:313-731-1844
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-05
Last Update Date:2019-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI372500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372500000XNursing Service Related ProvidersChore Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI7924786OtherPROVIDER HOME HELP
MI7924786Medicaid