Provider Demographics
NPI:1538269089
Name:WATKINS, JANINE DAVIS (OD)
Entity type:Individual
Prefix:DR
First Name:JANINE
Middle Name:DAVIS
Last Name:WATKINS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:JANINE
Other - Middle Name:
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:ODPC
Mailing Address - Street 1:201 PIKE ST
Mailing Address - Street 2:
Mailing Address - City:PORT CARBON
Mailing Address - State:PA
Mailing Address - Zip Code:17965-1504
Mailing Address - Country:US
Mailing Address - Phone:570-628-4147
Mailing Address - Fax:
Practice Address - Street 1:109 PIKE ST
Practice Address - Street 2:
Practice Address - City:PORT CARBON
Practice Address - State:PA
Practice Address - Zip Code:17965-1814
Practice Address - Country:US
Practice Address - Phone:570-622-7288
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEGOOO408152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAUO8995Medicare UPIN
PAWA639927Medicare ID - Type Unspecified