Basic Information
Provider Information | |||||||||
NPI: | 1629069778 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WATKIN | ||||||||
FirstName: | DOVE | ||||||||
MiddleName: | D | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1900 CENTRACARE CIR | ||||||||
Address2: |   | ||||||||
City: | SAINT CLOUD | ||||||||
State: | MN | ||||||||
PostalCode: | 563035000 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3206543630 | ||||||||
FaxNumber: | 3206543657 | ||||||||
Practice Location | |||||||||
Address1: | 1900 CENTRACARE CIR | ||||||||
Address2: |   | ||||||||
City: | SAINT CLOUD | ||||||||
State: | MN | ||||||||
PostalCode: | 563035000 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3206543630 | ||||||||
FaxNumber: | 3206543657 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/28/2005 | ||||||||
LastUpdateDate: | 12/13/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 37923 | MN | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 1027103 | 01 |   | PREFERRED ONE | OTHER | COMP | 01 |   | CHAMPUS | OTHER | 151800 | 01 |   | U CARE | OTHER | 40F76WA | 01 |   | BLUE CROSS BLUE SHIELD | OTHER | 3900974 | 01 |   | ARAZ GROUP AMERICAS PPO | OTHER | COMP | 01 |   | MMSI | OTHER | COMP | 01 |   | ONE HEALTH PLAN GREAT WES | OTHER | 1256322 | 01 |   | MEDICA HEALTH PLANS | OTHER | 575522100 | 05 | MN |   | MEDICAID | HP23202 | 01 |   | HEALTH PARTNERS | OTHER | 2129266 | 01 |   | FIRST HEALTH PLAN | OTHER |