Provider Demographics
NPI:1528094430
Name:WATKINS, LELAND E (MD)
Entity type:Individual
Prefix:
First Name:LELAND
Middle Name:E
Last Name:WATKINS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:LELAND
Other - Middle Name:E
Other - Last Name:WATKINS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
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
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG30953207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG30953OtherSTATE LICENSE NUMBER
CAW9267Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
CAG30953OtherSTATE LICENSE NUMBER