Provider Demographics
NPI:1689965741
Name:WATSON, JOHN SKELLY (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:SKELLY
Last Name:WATSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1820 S LYNN LANE RD
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74108-6300
Mailing Address - Country:US
Mailing Address - Phone:918-633-1967
Mailing Address - Fax:918-437-0072
Practice Address - Street 1:803 S JACKSON AVE
Practice Address - Street 2:SUITE 130
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74127-9010
Practice Address - Country:US
Practice Address - Phone:918-596-7075
Practice Address - Fax:918-596-7077
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-25
Last Update Date:2011-04-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK8871208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKD42914Medicare UPIN