Provider Demographics
NPI:1538466040
Name:WATSON, CARRIE DAWN (DO)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:DAWN
Last Name:WATSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2213 CHERRY ST
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43608-2603
Mailing Address - Country:US
Mailing Address - Phone:678-386-1753
Mailing Address - Fax:
Practice Address - Street 1:200 HERLONG AVE S STE G
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-1182
Practice Address - Country:US
Practice Address - Phone:803-909-6300
Practice Address - Fax:803-909-6310
Is Sole Proprietor?:No
Enumeration Date:2011-02-17
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS14726208600000X
390200000X
SC835698208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC835699Medicaid