Provider Demographics
NPI:1194866046
Name:WATSON, ELEANOR A (MD)
Entity Type:Individual
Prefix:
First Name:ELEANOR
Middle Name:A
Last Name:WATSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:804 SERVICE RD STE A202
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48824-7015
Mailing Address - Country:US
Mailing Address - Phone:517-349-6560
Mailing Address - Fax:517-349-5796
Practice Address - Street 1:1600 W GRAND RIVER AVE STE 2
Practice Address - Street 2:
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-2394
Practice Address - Country:US
Practice Address - Phone:517-349-6560
Practice Address - Fax:517-349-5796
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301083120208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIAAH000OtherHEALTHNET
MI350D410030OtherBLUE CROSS BLUE SHIELD
MI4915735Medicaid
MI1020845OtherMCLAREN HEALTH PLAN
MI200000006359OtherPHYSICIANS HEALTH PLAN