Basic Information
| Provider Information | |||||||||
| NPI: | 1619132321 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JEREMY P. WATKINS MD, L.L.C | ||||||||
| LastName: | |||||||||
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| MiddleName: | |||||||||
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| OtherOrganizationName: | JEREMY P. WATKINS MD, L.L.C | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1001 12TH AVE | ||||||||
| Address2: | SUITE150 | ||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761043926 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173358151 | ||||||||
| FaxNumber: | 8173352670 | ||||||||
| Practice Location | |||||||||
| Address1: | 1001 12TH AVE | ||||||||
| Address2: | SUITE150 | ||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761043926 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173358151 | ||||||||
| FaxNumber: | 8173352670 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2008 | ||||||||
| LastUpdateDate: | 07/22/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WATKINS | ||||||||
| AuthorizedOfficialFirstName: | JEREMY | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 8173358151 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | JEREMY P. WATKINS MD, L.L.C | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | M8419 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.