Provider Demographics
NPI:1437114618
Name:WATSON, JILL R (MD)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:R
Last Name:WATSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 950248
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40295-0248
Mailing Address - Country:US
Mailing Address - Phone:502-489-5730
Mailing Address - Fax:502-489-5753
Practice Address - Street 1:3900 KRESGE WAY
Practice Address - Street 2:SUITE 54
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4660
Practice Address - Country:US
Practice Address - Phone:502-896-6696
Practice Address - Fax:502-896-1795
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY39683207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200529550Medicaid
KY64109549Medicaid
I39385Medicare UPIN
KY64109549Medicaid