Provider Demographics
NPI:1568461374
Name:WATSON, MARSHALL TREDWAY JR (MD)
Entity Type:Individual
Prefix:DR
First Name:MARSHALL
Middle Name:TREDWAY
Last Name:WATSON
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:465 SAINT MICHAELS DR
Mailing Address - Street 2:SUITE 107
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-7670
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:465 SAINT MICHAELS DR
Practice Address - Street 2:SUITE 107
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-7670
Practice Address - Country:US
Practice Address - Phone:505-988-3233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-14
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN39694207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN39694OtherLICENSE
BW9241706OtherDEA
I34152Medicare UPIN