Provider Demographics
NPI:1275875965
Name:WATSON, TRACIE (DO)
Entity Type:Individual
Prefix:
First Name:TRACIE
Middle Name:
Last Name:WATSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 LENNON LN
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94598-2415
Mailing Address - Country:US
Mailing Address - Phone:925-939-9610
Mailing Address - Fax:925-939-9630
Practice Address - Street 1:500 LENNON LN
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94598-2415
Practice Address - Country:US
Practice Address - Phone:925-939-9610
Practice Address - Fax:925-939-9630
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-21
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILBF4649604-B213207R00000X, 208000000X
CA20A18558207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics