Provider Demographics
NPI:1609189638
Name:WATSON, JO ANN (MD)
Entity Type:Individual
Prefix:DR
First Name:JO
Middle Name:ANN
Last Name:WATSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:704 S WEBSTER AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-3528
Mailing Address - Country:US
Mailing Address - Phone:920-433-3456
Mailing Address - Fax:
Practice Address - Street 1:704 S WEBSTER AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3528
Practice Address - Country:US
Practice Address - Phone:920-433-3456
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-19
Last Update Date:2014-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI23900-20207Q00000X
CO49864207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WID33595Medicare UPIN
WI071700056Medicare Oscar/Certification
072900059Medicare Oscar/Certification
WI075100119Medicare Oscar/Certification
P0092982Medicare Oscar/Certification
WI590050052Medicare Oscar/Certification
WI1119013Medicare Oscar/Certification
002150233Medicare Oscar/Certification
WI100200066Medicare Oscar/Certification
WI430800038Medicare Oscar/Certification