Provider Demographics
NPI:1376587006
Name:WATSON, GARY RAY (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:RAY
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 1:2020 COFFEE RD.
Mailing Address - Street 2:STE. B-5
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355
Mailing Address - Country:US
Mailing Address - Phone:209-491-2000
Mailing Address - Fax:209-491-2787
Practice Address - Street 1:2020 COFFEE RD
Practice Address - Street 2:SUITE B-5
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-2427
Practice Address - Country:US
Practice Address - Phone:209-491-2000
Practice Address - Fax:209-491-2787
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2013-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG46720174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G46720Medicare ID - Type Unspecified
CAA50474Medicare UPIN