Provider Demographics
NPI:1073697843
Name:WATSON, LAWRENCE CHARLES (OD)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:CHARLES
Last Name:WATSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:73211 FRED WARING DR
Mailing Address - Street 2:#102
Mailing Address - City:PALM DESERT
Mailing Address - State:CA
Mailing Address - Zip Code:92260-2871
Mailing Address - Country:US
Mailing Address - Phone:760-346-1136
Mailing Address - Fax:760-568-1589
Practice Address - Street 1:73211 FRED WARING DR
Practice Address - Street 2:#102
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92260-2871
Practice Address - Country:US
Practice Address - Phone:760-346-1136
Practice Address - Fax:760-568-1589
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT5967TPL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0059670Medicaid
MW0658647OtherDEA
T10184Medicare UPIN
MW0658647OtherDEA
SD0059670Medicare PIN