Provider Demographics
NPI:1093749434
Name:WATSON, COURTLAND J (OD)
Entity Type:Individual
Prefix:
First Name:COURTLAND
Middle Name:J
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 1:2480 FAIRVIEW AVE N
Mailing Address - Street 2:ROSEDALE COMMONS
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-2699
Mailing Address - Country:US
Mailing Address - Phone:651-639-0407
Mailing Address - Fax:651-639-2503
Practice Address - Street 1:2480 FAIRVIEW AVE N
Practice Address - Street 2:ROSEDALE COMMONS
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-2699
Practice Address - Country:US
Practice Address - Phone:651-639-0407
Practice Address - Fax:651-639-2503
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2013-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2167152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN386219400Medicaid
MN386219400Medicaid
T39408Medicare UPIN