=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598811945
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IDAHO UROLOGY CLINIC, P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/26/2007
-----------------------------------------------------
Last Update Date | 11/09/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1613 12TH AVE RD STE B
-----------------------------------------------------
City | NAMPA
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83686-6183
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-466-2461
-----------------------------------------------------
Fax | 208-466-2488
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1613 12TH AVE RD STE B
-----------------------------------------------------
City | NAMPA
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83686-6183
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-466-2461
-----------------------------------------------------
Fax | 208-466-2488
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | WILFRED E WATKINS
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 208-466-2461
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | M2768
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------