Provider Demographics
NPI:1972604692
Name:WATKINS, MARK
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:WATKINS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3226 HAMPTON AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31520-4225
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3226 HAMPTON AVE
Practice Address - Street 2:SUITE A
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520-4225
Practice Address - Country:US
Practice Address - Phone:912-264-5768
Practice Address - Fax:912-264-5798
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA39262174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00739428AMedicaid
GA00739428AMedicaid
GAG54589Medicare UPIN