=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972704013
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KENNETH D WATKINS MD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/29/2007
-----------------------------------------------------
Last Update Date | 10/05/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 108 E HOSPITAL DR
-----------------------------------------------------
City | WINCHESTER
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47394-2223
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 765-584-1639
-----------------------------------------------------
Fax | 765-584-4711
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 108 E HOSPITAL DR
-----------------------------------------------------
City | WINCHESTER
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47394-2223
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 765-584-1639
-----------------------------------------------------
Fax | 765-584-4711
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. KENNETH D WATKINS
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 765-584-1639
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 01028715
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------