Provider Demographics
NPI:1063601888
Name:LELAND E WATKINS M D INC
Entity type:Organization
Organization Name:LELAND E WATKINS M D INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ADRIANA
Authorized Official - Middle Name:VEDA
Authorized Official - Last Name:SHEPHERD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-790-1145
Mailing Address - Street 1:1818 VERDUGO BLVD
Mailing Address - Street 2:SUITE 108
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91208-1403
Mailing Address - Country:US
Mailing Address - Phone:818-790-1145
Mailing Address - Fax:818-790-6387
Practice Address - Street 1:1818 VERDUGO BLVD
Practice Address - Street 2:SUITE 108
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91208-1403
Practice Address - Country:US
Practice Address - Phone:818-790-1145
Practice Address - Fax:818-790-6387
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-17
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG30953207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW9267Medicare PIN