Provider Demographics
NPI:1336144138
Name:WATSON, JEROME THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:JEROME
Middle Name:THOMAS
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 1:169 MONTIBELLO DR
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-9149
Mailing Address - Country:US
Mailing Address - Phone:704-872-6840
Mailing Address - Fax:
Practice Address - Street 1:293 OLD MOCKSVILLE ROAD
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28625-1903
Practice Address - Country:US
Practice Address - Phone:704-872-8711
Practice Address - Fax:704-872-5866
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9800413208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891129MMedicaid
NC498003002OtherDMERC
NCE69618Medicare UPIN
NC2234678DMedicare ID - Type UnspecifiedMEDICARE