Provider Demographics
NPI:1679869614
Name:WATKINS, JOHN RYAN (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:RYAN
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 1:2100 STANTONSBURG RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-2818
Mailing Address - Country:US
Mailing Address - Phone:252-744-4184
Mailing Address - Fax:252-744-4125
Practice Address - Street 1:777 N PALISADES DR
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84097-4341
Practice Address - Country:US
Practice Address - Phone:801-222-9200
Practice Address - Fax:385-203-0079
Is Sole Proprietor?:No
Enumeration Date:2011-06-28
Last Update Date:2020-05-28
Deactivation Date:2020-01-22
Deactivation Code:
Reactivation Date:2020-05-28
Provider Licenses
StateLicense IDTaxonomies
390200000X
UT11573862-1205208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program