Healthcare Provider Details

I. General information

NPI: 1043315369
Provider Name (Legal Business Name): TERRY WATKIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12007 SUNRISE VALLEY DR SUITE 120
RESTON VA
20191-3479
US

IV. Provider business mailing address

PO BOX 79429
BALTIMORE MD
21279-0429
US

V. Phone/Fax

Practice location:
  • Phone: 301-624-5730
  • Fax: 301-624-5731
Mailing address:
  • Phone: 301-624-5730
  • Fax: 301-624-5731

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number010104747
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: