Provider Demographics
NPI:1043315369
Name:WATKIN, TERRY (MD)
Entity type:Individual
Prefix:
First Name:TERRY
Middle Name:
Last Name:WATKIN
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:PO BOX 79429
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21279-0429
Mailing Address - Country:US
Mailing Address - Phone:301-624-5730
Mailing Address - Fax:301-624-5731
Practice Address - Street 1:12007 SUNRISE VALLEY DR
Practice Address - Street 2:SUITE 120
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20191-3479
Practice Address - Country:US
Practice Address - Phone:301-624-5730
Practice Address - Fax:301-624-5731
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA010104747174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC4571 0003OtherCF BC BS DC
VA007110341Medicaid
VA0500138OtherUNITED HEALTHCARE
VA244468OtherANTHEM
VA283590OtherAMERIGROUP
VA4053661OtherAETNA
MD535088 02OtherCF BC BS MD/NASCO
VA85488OtherMAMSI/ALLIANCE
VA130018728OtherRAILROAD MEDICARE
VA505096OtherNCPPO
VA244468OtherANTHEM
VA505096OtherNCPPO