Provider Demographics
NPI:1255305322
Name:WATSON, MATTHEW J (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:J
Last Name:WATSON
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:PO BOX 2968
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30156-9117
Mailing Address - Country:US
Mailing Address - Phone:770-779-0015
Mailing Address - Fax:
Practice Address - Street 1:1000 JOHNSON FERRY RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1606
Practice Address - Country:US
Practice Address - Phone:404-851-6936
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2008-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA049822207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000917727HMedicaid
GA000917727IMedicaid
GA008892OtherBCBS
GA000917727Medicaid
GA10038154OtherAMERIGROUP
GA298003OtherBCBS
GA333417OtherWELLCARE
GA10654OtherKAISER
GA000917727IMedicaid
GA298003OtherBCBS
GA10654OtherKAISER
GA008892OtherBCBS