1528094430 NPI number — LELAND E WATKINS MD

Table of content: LELAND E WATKINS MD (NPI 1528094430)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528094430 NPI number — LELAND E WATKINS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WATKINS
Provider First Name:
LELAND
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
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:
WATKINS
Provider Other First Name:
LELAND
Provider Other Middle Name:
E
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1528094430
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/02/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1818 VERDUGO BLVD
Provider Second Line Business Mailing Address:
SUITE 108
Provider Business Mailing Address City Name:
GLENDALE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91208-1403
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-790-1145
Provider Business Mailing Address Fax Number:
818-790-6387

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1818 VERDUGO BLVD
Provider Second Line Business Practice Location Address:
SUITE 108
Provider Business Practice Location Address City Name:
GLENDALE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91208-1403
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-790-1145
Provider Business Practice Location Address Fax Number:
818-790-6387
Provider Enumeration Date:
06/23/2006

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: 207Q00000X , with the licence number:  G30953 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: G30953 . This is a "STATE LICENSE NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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