Provider Demographics
NPI:1336104108
Name:WATSON, JAN D (MD)
Entity Type:Individual
Prefix:DR
First Name:JAN
Middle Name:D
Last Name:WATSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2030 W BASELINE RD STE 182-235
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85041-6579
Mailing Address - Country:US
Mailing Address - Phone:602-899-3923
Mailing Address - Fax:602-833-2549
Practice Address - Street 1:2030 W BASELINE RD
Practice Address - Street 2:SUITE 182-235
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85041-6574
Practice Address - Country:US
Practice Address - Phone:602-957-2407
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-17
Last Update Date:2019-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ24951207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
03-1881OtherMEDICARE
Z148521OtherMEDICARE
AZ279689Medicaid
ZFQ31815OtherMEDICARE