Provider Demographics
NPI:1184611600
Name:WATKINS, LARA B (MD)
Entity type:Individual
Prefix:MRS
First Name:LARA
Middle Name:B
Last Name:WATKINS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LARA
Other - Middle Name:
Other - Last Name:RAYAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:35 COLLIER ROAD, NW
Mailing Address - Street 2:SUITE 610
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309
Mailing Address - Country:US
Mailing Address - Phone:404-355-7375
Mailing Address - Fax:404-350-9781
Practice Address - Street 1:35 COLLIER ROAD, NW
Practice Address - Street 2:SUITE 610
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309
Practice Address - Country:US
Practice Address - Phone:404-355-7375
Practice Address - Fax:404-350-9781
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2009-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA050280174400000X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAPENDINGMedicaid
H39848Medicare UPIN
GA39BDCLJMedicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
GAPENDINGMedicaid