Healthcare Provider Details

I. General information

NPI: 1922098664
Provider Name (Legal Business Name): TIMOTHY WELLS WATKINS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2005
Last Update Date: 04/28/2022
Certification Date: 04/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

385 PROSPECT AVE STE 210
HACKENSACK NJ
07601-2570
US

IV. Provider business mailing address

385 PROSPECT AVE STE 210
HACKENSACK NJ
07601-2570
US

V. Phone/Fax

Practice location:
  • Phone: 551-996-9175
  • Fax: 551-991-9165
Mailing address:
  • Phone: 551-996-9175
  • Fax: 551-991-9165

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number150768
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier150768
Identifier TypeOTHER
Identifier StateMA
Identifier IssuerTUFTS HEALTH PLAN
# 2
Identifier3194914
Identifier TypeMEDICAID
Identifier StateMA
Identifier Issuer
# 3
IdentifierJ21512
Identifier TypeOTHER
Identifier StateMA
Identifier IssuerBCBS MA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: