Provider Demographics
NPI:1467500181
Name:WATSON, BEN GERVAS (MD)
Entity Type:Individual
Prefix:
First Name:BEN
Middle Name:GERVAS
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 1:840 S FAIRMONT AVE
Mailing Address - Street 2:STE. 9
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95240-5105
Mailing Address - Country:US
Mailing Address - Phone:209-333-1751
Mailing Address - Fax:
Practice Address - Street 1:840 S FAIRMONT AVE
Practice Address - Street 2:SUITE 9
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240-5105
Practice Address - Country:US
Practice Address - Phone:209-333-1751
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA40293204C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports Medicine