Provider Demographics
NPI:1174542856
Name:WATKINS, THEODORE LOUIS II (MD)
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:LOUIS
Last Name:WATKINS
Suffix:II
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3834 GATEWAY TER
Mailing Address - Street 2:
Mailing Address - City:BURTONSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20866-2107
Mailing Address - Country:US
Mailing Address - Phone:240-462-4785
Mailing Address - Fax:
Practice Address - Street 1:323 15TH ST NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20002-6501
Practice Address - Country:US
Practice Address - Phone:202-388-0992
Practice Address - Fax:240-331-1090
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC33780208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC7177312333Medicaid
430362Medicare ID - Type Unspecified
C88943Medicare UPIN