Provider Demographics
NPI:1598803314
Name:WATANABE, MICHAEL J (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:WATANABE
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 1:24401 CALLE DE LA LOUISA
Mailing Address - Street 2:SUITE 102
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653
Mailing Address - Country:US
Mailing Address - Phone:949-859-8551
Mailing Address - Fax:949-859-3640
Practice Address - Street 1:24401 CALLE DE LA LOUISA
Practice Address - Street 2:SUITE 102
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653
Practice Address - Country:US
Practice Address - Phone:949-859-8551
Practice Address - Fax:949-859-3640
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA29824208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
A29824Medicare ID - Type Unspecified
A84011Medicare UPIN