Provider Demographics
NPI:1235185620
Name:DESA, WATSON A (MD)
Entity Type:Individual
Prefix:
First Name:WATSON
Middle Name:A
Last Name:DESA
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 1:3851 KATELLA AVE STE 305
Mailing Address - Street 2:
Mailing Address - City:LOS ALAMITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90720-3390
Mailing Address - Country:US
Mailing Address - Phone:562-594-6080
Mailing Address - Fax:562-594-6030
Practice Address - Street 1:3851 KATELLA AVE STE 305
Practice Address - Street 2:
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720-3390
Practice Address - Country:US
Practice Address - Phone:562-594-6080
Practice Address - Fax:562-594-6030
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-26
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA32717207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA32717Medicare ID - Type UnspecifiedPROVIDER NO.
A26904Medicare UPIN