Healthcare Provider Details

I. General information

NPI: 1972704013
Provider Name (Legal Business Name): KENNETH D WATKINS MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2007
Last Update Date: 10/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 E HOSPITAL DR
WINCHESTER IN
47394-2223
US

IV. Provider business mailing address

108 E HOSPITAL DR
WINCHESTER IN
47394-2223
US

V. Phone/Fax

Practice location:
  • Phone: 765-584-1639
  • Fax: 765-584-4711
Mailing address:
  • Phone: 765-584-1639
  • Fax: 765-584-4711

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01028715
License Number StateIN

VIII. Authorized Official

Name: DR. KENNETH D WATKINS
Title or Position: OWNER
Credential: MD
Phone: 765-584-1639