Provider Demographics
NPI:1568453991
Name:WATSON, PHILLIP (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:
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 1:13185 CORONADO DR
Mailing Address - Street 2:
Mailing Address - City:NORTH MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33181-2153
Mailing Address - Country:US
Mailing Address - Phone:305-213-7980
Mailing Address - Fax:
Practice Address - Street 1:13185 CORONADO DR
Practice Address - Street 2:
Practice Address - City:NORTH MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33181-2153
Practice Address - Country:US
Practice Address - Phone:305-213-7980
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-03
Last Update Date:2015-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 30462208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
D60207Medicare UPIN