Provider Demographics
NPI:1487653655
Name:WATSON, RANDY CHARLES (MD)
Entity Type:Individual
Prefix:DR
First Name:RANDY
Middle Name:CHARLES
Last Name:WATSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 11889
Mailing Address - Street 2:
Mailing Address - City:ZEPHYR COVE
Mailing Address - State:NV
Mailing Address - Zip Code:89448-3889
Mailing Address - Country:US
Mailing Address - Phone:775-588-3636
Mailing Address - Fax:775-588-1299
Practice Address - Street 1:212 ELKS POINT ROAD
Practice Address - Street 2:SUITE 200
Practice Address - City:ZEPHYR COVE
Practice Address - State:NV
Practice Address - Zip Code:89448
Practice Address - Country:US
Practice Address - Phone:775-588-3636
Practice Address - Fax:775-588-1299
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NV3188207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV2003284Medicaid
NVA35318Medicare UPIN
NV2003284Medicaid