Provider Demographics
NPI:1316134158
Name:WATKINS, JAMES WILLIAM IV (MD)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:WILLIAM
Last Name:WATKINS
Suffix:IV
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 1:2511 NW MILDRED ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-3336
Mailing Address - Country:US
Mailing Address - Phone:503-295-9545
Mailing Address - Fax:
Practice Address - Street 1:2511 NW MILDRED ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-3336
Practice Address - Country:US
Practice Address - Phone:503-295-9545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-25
Last Update Date:2008-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00048178208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAGAB32999OtherMEDICARE GROUP
WA8485781Medicaid