Provider Demographics
NPI:1508837691
Name:WATSON, SUSAN JANE (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:JANE
Last Name:WATSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 E SOUTH HILLS DR
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:64468-2659
Mailing Address - Country:US
Mailing Address - Phone:660-562-4304
Mailing Address - Fax:660-562-4303
Practice Address - Street 1:114 E SOUTH HILLS DR
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:MO
Practice Address - Zip Code:64468-2659
Practice Address - Country:US
Practice Address - Phone:660-562-2525
Practice Address - Fax:660-562-4303
Is Sole Proprietor?:No
Enumeration Date:2006-01-28
Last Update Date:2012-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO110025208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO208219816Medicaid
MOE41864Medicare UPIN
MOE269224Medicare PIN