Provider Demographics
NPI:1689856981
Name:CAPSTONE MEDICAL GROUP
Entity Type:Organization
Organization Name:CAPSTONE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:CLYDE
Authorized Official - Middle Name:
Authorized Official - Last Name:WATKINS
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:404-446-3870
Mailing Address - Street 1:5900 HILLANDALE DR
Mailing Address - Street 2:ANNEX E
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30058-3802
Mailing Address - Country:US
Mailing Address - Phone:404-446-3870
Mailing Address - Fax:404-446-3875
Practice Address - Street 1:5900 HILLANDALE DR
Practice Address - Street 2:ANNEX E
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30058-3802
Practice Address - Country:US
Practice Address - Phone:404-446-3870
Practice Address - Fax:404-446-3875
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-29
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA036033174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP7352Medicare PIN
GAF32267Medicare UPIN