Provider Demographics
NPI:1053349860
Name:WATKINS, JEFFREY W (MD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:W
Last Name:WATKINS
Suffix:
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 1:1300 ANNE ST NW
Mailing Address - Street 2:
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601-5103
Mailing Address - Country:US
Mailing Address - Phone:218-333-5000
Mailing Address - Fax:
Practice Address - Street 1:350 HERITAGE WAY STE 2100
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-3167
Practice Address - Country:US
Practice Address - Phone:406-257-8992
Practice Address - Fax:406-275-8996
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD24781207RC0000X, 207R00000X, 207RI0011X
MN53673207RI0011X, 207RC0000X
MTMED-PHYS-LIC-66555207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORE69397Medicare UPIN