Provider Demographics
NPI:1992781090
Name:WATKINS, SANFORD (MD)
Entity type:Individual
Prefix:
First Name:SANFORD
Middle Name:
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 1:709 HOLLYBROOK DR
Mailing Address - Street 2:SUITE 4500
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75605-2411
Mailing Address - Country:US
Mailing Address - Phone:903-757-6042
Mailing Address - Fax:903-232-8233
Practice Address - Street 1:709 HOLLYBROOK DR
Practice Address - Street 2:SUITE 4500
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605-2411
Practice Address - Country:US
Practice Address - Phone:903-757-6042
Practice Address - Fax:903-232-8233
Is Sole Proprietor?:No
Enumeration Date:2005-12-20
Last Update Date:2012-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM3109207R00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP00387831OtherRR MEDICARE
TX178792103Medicaid
I48549Medicare UPIN
TXP00387831OtherRR MEDICARE