Provider Demographics
NPI:1093475824
Name:MARY CAROLYN WATSON
Entity Type:Organization
Organization Name:MARY CAROLYN WATSON
Other - Org Name:MARY WATSON MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:WATSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-815-0063
Mailing Address - Street 1:3361 SHADOWMOSS DR
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-5678
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:608 DOGWOOD DR NE
Practice Address - Street 2:
Practice Address - City:PELHAM
Practice Address - State:GA
Practice Address - Zip Code:31779-1132
Practice Address - Country:US
Practice Address - Phone:850-815-0063
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-21
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1053549444OtherNPI
GA86385OtherGA MEDICAL LICENSE