Provider Demographics
NPI:1447431275
Name:WATKINS, JEREMIAH RAY (MD)
Entity type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:RAY
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 1:9600 DATAPOINT DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-2028
Mailing Address - Country:US
Mailing Address - Phone:210-892-3720
Mailing Address - Fax:210-617-4692
Practice Address - Street 1:9600 DATAPOINT DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-2028
Practice Address - Country:US
Practice Address - Phone:210-892-3700
Practice Address - Fax:210-617-4692
Is Sole Proprietor?:No
Enumeration Date:2007-11-20
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA059231207ZP0105X
GA59231207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA11016OtherMED DIRECTOR LIC
FL160548OtherSTATE MED LIC
SC89012OtherSTATE MED LIC
GA003126490CMedicaid
TXV0576OtherSTATE MED LIC
GA059231OtherSTATE LICENCSE
NC2022-03227OtherSTATE MED LIC
GA003126490DMedicaid