Basic Information
| Provider Information | |||||||||
| NPI: | 1932186566 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WATKINS | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | WILLIAM | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2111 OGDEN AVE | ||||||||
| Address2: | |||||||||
| City: | AURORA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605047597 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6309783800 | ||||||||
| FaxNumber: | 6308623085 | ||||||||
| Practice Location | |||||||||
| Address1: | 2111 OGDEN AVE | ||||||||
| Address2: | |||||||||
| City: | AURORA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605047597 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6309783800 | ||||||||
| FaxNumber: | 6308623086 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/23/2005 | ||||||||
| LastUpdateDate: | 07/21/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | 016004906 | IL | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | 213ES0131X | 016004906 | IL | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot Surgery |
ID Information
| ID | Type | State | Issuer | Description | 016004906 | 05 | IL | MEDICAID |