Provider Demographics
NPI:1144211699
Name:WATNICK, RICHARD L (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:L
Last Name:WATNICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25350 KELLY RD
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48066-4904
Mailing Address - Country:US
Mailing Address - Phone:586-772-1990
Mailing Address - Fax:586-772-1137
Practice Address - Street 1:25350 KELLY RD
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48066-5824
Practice Address - Country:US
Practice Address - Phone:586-772-1990
Practice Address - Fax:586-772-1137
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301405297207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
0500199Medicare ID - Type Unspecified
B47583Medicare UPIN