Provider Demographics
NPI:1679683668
Name:WATKINS, MARLAINA DEANN (OD)
Entity Type:Individual
Prefix:DR
First Name:MARLAINA
Middle Name:DEANN
Last Name:WATKINS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:MARLAINA
Other - Middle Name:DEANN
Other - Last Name:FLETCHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:12574 SW AUTUMN VIEW ST
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-0707
Mailing Address - Country:US
Mailing Address - Phone:503-708-4213
Mailing Address - Fax:
Practice Address - Street 1:19400 NW EVERGREEN PKWY
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97124-7031
Practice Address - Country:US
Practice Address - Phone:971-310-2515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2015-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00003275152W00000X
OR2585AT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORU62613Medicare UPIN