Healthcare Provider Details

I. General information

NPI: 1154305472
Provider Name (Legal Business Name): MICHAEL T WATKINS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2005
Last Update Date: 01/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 PARKMAN ST WAC 458
BOSTON MA
02114-3117
US

IV. Provider business mailing address

PO BOX 9142
CHARLESTOWN MA
02129-9142
US

V. Phone/Fax

Practice location:
  • Phone: 617-726-0908
  • Fax: 617-726-2560
Mailing address:
  • Phone: 617-726-0908
  • Fax: 617-726-2560

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number56029
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: