1417206095 NPI number — DR. ROBERT LEE WATKINS III MD

Table of content: DR. ROBERT LEE WATKINS III MD (NPI 1417206095)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417206095 NPI number — DR. ROBERT LEE WATKINS III MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WATKINS
Provider First Name:
ROBERT
Provider Middle Name:
LEE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
III
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417206095
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/10/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1230 TADSWORTH TER
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKE MARY
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32746-5336
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-729-0852
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1177 LOUISIANA AVE STE 209
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WINTER PARK
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32789-2352
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-664-8242
Provider Business Practice Location Address Fax Number:
407-960-6284
Provider Enumeration Date:
08/29/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2084P0804X , with the licence number:  ME126649 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 109958500 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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