Provider Demographics
NPI:1467445965
Name:WATSON, MARY TALLY (OD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:TALLY
Last Name:WATSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15933 CLAYTON RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63011-2172
Mailing Address - Country:US
Mailing Address - Phone:636-200-4393
Mailing Address - Fax:636-527-0766
Practice Address - Street 1:7880 OLD MADISON PIKE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:AL
Practice Address - Zip Code:35758-1435
Practice Address - Country:US
Practice Address - Phone:256-772-8711
Practice Address - Fax:256-772-8738
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS817TA165152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051519133Medicare PIN
U60039Medicare UPIN
ALU60039Medicare UPIN
AL1074080011Medicare NSC