Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 111N00000X | Chiropractor | IL | |
N | 111NS0005X | Chiropractic Sports Physician | IL |
NPI | 1306821046 |
---|---|
Provider Name | Dr. Jeffrey Watkin |
First Address | Libertyville, IL 60048-5000 |
Second Address | Libertyville, IL 60048-5000 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/12/2005 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
T37690 | (02) | IL |