Healthcare Provider Details

I. General information

NPI: 1184611600
Provider Name (Legal Business Name): LARA B WATKINS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LARA RAYAN M.D.

II. Dates (important events)

Enumeration Date: 09/30/2005
Last Update Date: 07/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 COLLIER ROAD, NW SUITE 610
ATLANTA GA
30309
US

IV. Provider business mailing address

35 COLLIER ROAD, NW SUITE 610
ATLANTA GA
30309
US

V. Phone/Fax

Practice location:
  • Phone: 404-355-7375
  • Fax: 404-350-9781
Mailing address:
  • Phone: 404-355-7375
  • Fax: 404-350-9781

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number050280
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number050280
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: