Provider Demographics
NPI:1508097015
Name:WATSON, BRYAN LEE (DO)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:LEE
Last Name:WATSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:999 EXECUTIVE PARK BLVD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-4632
Mailing Address - Country:US
Mailing Address - Phone:423-224-3250
Mailing Address - Fax:423-224-3258
Practice Address - Street 1:323 CLOVERLEAF SQ
Practice Address - Street 2:#1
Practice Address - City:BIG STONE GAP
Practice Address - State:VA
Practice Address - Zip Code:24219-2760
Practice Address - Country:US
Practice Address - Phone:276-523-6715
Practice Address - Fax:276-523-6719
Is Sole Proprietor?:No
Enumeration Date:2009-07-31
Last Update Date:2012-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0116021762207R00000X
VA0102202658207P00000X, 207R00000X
KY03406207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1522495Medicaid
VA1508097015Medicaid
KY7100137290Medicaid
NC7617286Medicaid
VA1508097015Medicaid
NC7617286Medicaid