Provider Demographics
NPI:1235142894
Name:WATSON, HENRY GEOFFREY (MD)
Entity Type:Individual
Prefix:DR
First Name:HENRY
Middle Name:GEOFFREY
Last Name:WATSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:GEOFFREY
Other - Middle Name:HENRY
Other - Last Name:WATSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5709 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94608-2811
Mailing Address - Country:US
Mailing Address - Phone:510-444-9460
Mailing Address - Fax:510-444-1966
Practice Address - Street 1:5709 MARKET ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94608-2811
Practice Address - Country:US
Practice Address - Phone:510-444-9460
Practice Address - Fax:510-444-1966
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2013-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC41403174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C414031Medicaid
CA00C414031Medicare ID - Type UnspecifiedSOLO PRACTICE
CA00C414031Medicaid