Provider Demographics
NPI:1417914516
Name:WATSON, JASON LEE (MD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:LEE
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:PO BOX 2168
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29304-2168
Mailing Address - Country:US
Mailing Address - Phone:864-560-4304
Mailing Address - Fax:864-560-4413
Practice Address - Street 1:133 N HOWARD AVE
Practice Address - Street 2:
Practice Address - City:LANDRUM
Practice Address - State:SC
Practice Address - Zip Code:29356-1507
Practice Address - Country:US
Practice Address - Phone:864-457-3838
Practice Address - Fax:864-560-9532
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2008-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCTL30486207Q00000X
NC207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCN00433Medicaid
NC5900329Medicaid
NCI26011Medicare UPIN
NC2037833AMedicare PIN