Provider Demographics
NPI:1689637258
Name:WATINE, ROBERT S (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:S
Last Name:WATINE
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:PO BOX 560010
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32956-0010
Mailing Address - Country:US
Mailing Address - Phone:321-729-1400
Mailing Address - Fax:321-728-5700
Practice Address - Street 1:5205 BABCOCK ST NE
Practice Address - Street 2:SUITE 3
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32905-4638
Practice Address - Country:US
Practice Address - Phone:321-729-1400
Practice Address - Fax:321-728-5700
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2018-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME51370207R00000X
PAMD456500207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME51370OtherFLORIDA MEDICAL LICENSE
PAMD456500OtherPENNSYLVANIA MEDICAL LICENSE