Provider Demographics
NPI:1700856861
Name:WATSON, MARK RAYMOND (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:RAYMOND
Last Name:WATSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:DR
Other - First Name:MARK
Other - Middle Name:RAYMOND
Other - Last Name:WATSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:3437 DEER OAK CIR
Mailing Address - Street 2:
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32766-8111
Mailing Address - Country:US
Mailing Address - Phone:904-589-8512
Mailing Address - Fax:904-579-4268
Practice Address - Street 1:3175 CHENEY HWY
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32780-5979
Practice Address - Country:US
Practice Address - Phone:321-383-8040
Practice Address - Fax:321-267-1544
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-23
Last Update Date:2014-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC-4076152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLCX186AOtherMEDICARE PTAN