Provider Demographics
NPI:1962784975
Name:WATKINS, BLAINE KENNETH (OD)
Entity type:Individual
Prefix:MR
First Name:BLAINE
Middle Name:KENNETH
Last Name:WATKINS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1155 S POWER RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-3715
Mailing Address - Country:US
Mailing Address - Phone:210-319-8099
Mailing Address - Fax:
Practice Address - Street 1:1155 S POWER RD
Practice Address - Street 2:SUITE 102
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-3715
Practice Address - Country:US
Practice Address - Phone:210-319-8099
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-15
Last Update Date:2015-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AZ2060152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program