Provider Demographics
NPI:1659366433
Name:WATSON, WILLIE CLYDE III (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIE
Middle Name:CLYDE
Last Name:WATSON
Suffix:III
Gender:M
Credentials:MD
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Mailing Address - Street 1:2409 W ILLINOIS AVE
Mailing Address - Street 2:STE D
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79701-6307
Mailing Address - Country:US
Mailing Address - Phone:432-620-8687
Mailing Address - Fax:432-682-1831
Practice Address - Street 1:2409 W ILLINOIS AVE
Practice Address - Street 2:STE D
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79701-6307
Practice Address - Country:US
Practice Address - Phone:432-620-8687
Practice Address - Fax:432-682-1831
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-16
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TXE2924208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXG36868Medicare UPIN