Provider Demographics
NPI:1568450104
Name:WATSON, FREDERICK S (MD)
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:S
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 1:325 DISTEL CIR
Mailing Address - Street 2:
Mailing Address - City:LOS ALTOS
Mailing Address - State:CA
Mailing Address - Zip Code:94022-1408
Mailing Address - Country:US
Mailing Address - Phone:650-652-8600
Mailing Address - Fax:
Practice Address - Street 1:50 S SAN MATEO DR
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94401-3857
Practice Address - Country:US
Practice Address - Phone:650-652-8600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-07
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA48257207RI0011X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A482570Medicaid
CA00A482570Medicaid
CAE63784Medicare UPIN