Healthcare Provider Details

I. General information

NPI: 1982845897
Provider Name (Legal Business Name): TIFFANY L BOLDEN-WATKINS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2009
Last Update Date: 04/11/2023
Certification Date: 04/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 CITY BLVD
WAYCROSS GA
31501-8003
US

IV. Provider business mailing address

505 CITY BLVD
WAYCROSS GA
31501-8003
US

V. Phone/Fax

Practice location:
  • Phone: 912-490-2229
  • Fax: 912-490-9023
Mailing address:
  • Phone: 912-490-2229
  • Fax: 912-490-9023

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number302780
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberMD.206395
License Number StateLA
# 4
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number69677
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: