Provider Demographics
NPI:1972704013
Name:KENNETH D WATKINS MD
Entity Type:Organization
Organization Name:KENNETH D WATKINS MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:D
Authorized Official - Last Name:WATKINS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:765-584-1639
Mailing Address - Street 1:108 E HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:IN
Mailing Address - Zip Code:47394-2223
Mailing Address - Country:US
Mailing Address - Phone:765-584-1639
Mailing Address - Fax:765-584-4711
Practice Address - Street 1:108 E HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:IN
Practice Address - Zip Code:47394-2223
Practice Address - Country:US
Practice Address - Phone:765-584-1639
Practice Address - Fax:765-584-4711
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-29
Last Update Date:2011-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01028715207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN169670OtherREGULAR MEDICARE
IN00000008478OtherANTHEM
IN200399280AMedicaid