Provider Demographics
NPI:1629387790
Name:MICHAEL J. WATANABE, M.D., APC
Entity Type:Organization
Organization Name:MICHAEL J. WATANABE, M.D., APC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JUN
Authorized Official - Last Name:WATANABE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-859-8551
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:92653-3623
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:92653-3623
Practice Address - Country:US
Practice Address - Phone:949-859-8551
Practice Address - Fax:949-859-3640
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-06
Last Update Date:2010-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA298242086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA29824Medicare UPIN