Provider Demographics
NPI:1336226166
Name:WATKINS, MARK THOMAS (DO)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:THOMAS
Last Name:WATKINS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:253 S 10TH ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-5751
Mailing Address - Country:US
Mailing Address - Phone:215-829-0170
Mailing Address - Fax:215-829-0173
Practice Address - Street 1:253 SO 10TH STREET
Practice Address - Street 2:SUITE 201
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-5605
Practice Address - Country:US
Practice Address - Phone:215-829-0170
Practice Address - Fax:215-829-0173
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2009-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS006195L207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAF10473Medicare UPIN