Provider Demographics
NPI:1710981162
Name:WATKINS, WILFRED E (MD, FACS)
Entity Type:Individual
Prefix:DR
First Name:WILFRED
Middle Name:E
Last Name:WATKINS
Suffix:
Gender:M
Credentials:MD, FACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1613 12TH AVE RD STE B
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-6183
Mailing Address - Country:US
Mailing Address - Phone:208-466-2461
Mailing Address - Fax:208-466-2488
Practice Address - Street 1:1613 12TH AVE RD
Practice Address - Street 2:STE B
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-6183
Practice Address - Country:US
Practice Address - Phone:208-466-2461
Practice Address - Fax:208-466-2488
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-13
Last Update Date:2010-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM2768174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1710981162OtherINDIVIDUAL NPI
ID1370335OtherMEDICARE CLINIC NUMBER
ID1598811945OtherNPI CORPORATION NUMBER
ID002409100Medicaid
ID1598811945OtherNPI CORPORATION NUMBER
ID1370335OtherMEDICARE CLINIC NUMBER
ID002409100Medicaid