Provider Demographics
NPI:1407099328
Name:WATSON, DARYL STEVEN JR (CRNA)
Entity Type:Individual
Prefix:MR
First Name:DARYL
Middle Name:STEVEN
Last Name:WATSON
Suffix:JR
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1933 W 85TH AVE
Mailing Address - Street 2:APT M383
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-8801
Mailing Address - Country:US
Mailing Address - Phone:708-373-4541
Mailing Address - Fax:
Practice Address - Street 1:1770 1ST ST
Practice Address - Street 2:SUITE 703
Practice Address - City:HIGHLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60035-3200
Practice Address - Country:US
Practice Address - Phone:847-404-9046
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-07
Last Update Date:2010-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041-344775163W00000X
IL209007714367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$001Medicaid
IL202783010Medicare PIN