Provider Demographics
NPI:1629292016
Name:KENNETH R WATSON DO PC
Entity Type:Organization
Organization Name:KENNETH R WATSON DO PC
Other - Org Name:THE CLINIC ON MAIN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:R
Authorized Official - Last Name:WATSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:DO
Authorized Official - Phone:405-321-1497
Mailing Address - Street 1:2121 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73069-6459
Mailing Address - Country:US
Mailing Address - Phone:405-321-1497
Mailing Address - Fax:
Practice Address - Street 1:2121 W MAIN ST
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73069-6459
Practice Address - Country:US
Practice Address - Phone:405-321-1497
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3796208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty