Basic Information
| Provider Information | |||||||||
| NPI: | 1689667669 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WATKINS | ||||||||
| FirstName: | TRACI | ||||||||
| MiddleName: | N | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3909 WOODLEY RD | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436061169 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192912670 | ||||||||
| FaxNumber: | 4194796017 | ||||||||
| Practice Location | |||||||||
| Address1: | 3909 WOODLEY RD | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436061169 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192912670 | ||||||||
| FaxNumber: | 4194796017 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2005 | ||||||||
| LastUpdateDate: | 02/17/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 35074048 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2313822 | 01 | OH | AETNA | OTHER | 080161014 | 01 | OH | RRMC | OTHER | 2153931 | 05 | OH | MEDICAID | 03491 | 01 | PARAMOUNT | OTHER | 01-04929 | 01 | OH | UHC | OTHER | 203089 | 01 | OH | BLACK LUNG | OTHER | 000000141223 | 01 | OH | ANTHEM | OTHER |