Provider Demographics
NPI:1306815485
Name:WATSON, HERMAN (MD)
Entity Type:Individual
Prefix:DR
First Name:HERMAN
Middle Name:
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 1:209 NW PONDEROSA ST
Mailing Address - Street 2:
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64064-1462
Mailing Address - Country:US
Mailing Address - Phone:816-523-1177
Mailing Address - Fax:816-523-2521
Practice Address - Street 1:1734 E 63RD ST
Practice Address - Street 2:SUITE 460
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64110-3543
Practice Address - Country:US
Practice Address - Phone:816-523-1177
Practice Address - Fax:816-523-2521
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-14
Last Update Date:2010-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR6315174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS10000400AMedicaid
MO200473916Medicaid
MO200473916Medicaid
KS10000400AMedicaid