Provider Demographics
NPI:1033127816
Name:WATSON, GONZZO (DC)
Entity Type:Individual
Prefix:DR
First Name:GONZZO
Middle Name:
Last Name:WATSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:DR
Other - First Name:MATTHEW
Other - Middle Name:ALLEN
Other - Last Name:WATSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:18670 WILLAMETTE DRIVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:WEST LINN
Mailing Address - State:OR
Mailing Address - Zip Code:97068
Mailing Address - Country:US
Mailing Address - Phone:503-697-7463
Mailing Address - Fax:503-697-2743
Practice Address - Street 1:18670 WILLAMETTE DRIVE
Practice Address - Street 2:SUITE 101
Practice Address - City:WEST LINN
Practice Address - State:OR
Practice Address - Zip Code:97068
Practice Address - Country:US
Practice Address - Phone:503-697-7463
Practice Address - Fax:503-697-2743
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR272973111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR158842Medicaid
UT350555OtherMEDICARE RR PARTB
OR808027000OtherBLUE CROSS BLUE SHIELD
OR158842Medicaid