Provider Demographics
NPI:1184661209
Name:WATKINS, LAURENCE OCTAVIUS (MD)
Entity type:Individual
Prefix:
First Name:LAURENCE
Middle Name:OCTAVIUS
Last Name:WATKINS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 SE HILLMOOR DRIVE
Mailing Address - Street 2:C208
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952
Mailing Address - Country:US
Mailing Address - Phone:772-337-5083
Mailing Address - Fax:772-337-5088
Practice Address - Street 1:1801 SE HILLMOOR DRIVE
Practice Address - Street 2:C208
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952
Practice Address - Country:US
Practice Address - Phone:772-337-5083
Practice Address - Fax:772-337-5088
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1300007207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL042099900Medicaid
P00174268OtherRR MEDICARE
D42037Medicare UPIN
61473Medicare ID - Type Unspecified