Provider Demographics
NPI:1710091822
Name:WATSON, YASMIRA IVETTE (MD)
Entity Type:Individual
Prefix:
First Name:YASMIRA
Middle Name:IVETTE
Last Name:WATSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11155 DUNN RD
Mailing Address - Street 2:STE: 315E
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63136-6150
Mailing Address - Country:US
Mailing Address - Phone:314-355-7500
Mailing Address - Fax:314-355-3287
Practice Address - Street 1:11155 DUNN RD
Practice Address - Street 2:STE: 315E
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63136-6150
Practice Address - Country:US
Practice Address - Phone:314-355-7500
Practice Address - Fax:314-355-3287
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO36905207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO202826327Medicaid
MO202826327Medicaid
MO961193481Medicare ID - Type Unspecified