Provider Demographics
NPI:1710583125
Name:WATSON, MARK STEVEN
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:STEVEN
Last Name:WATSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 RITCHIE AVE # 411
Mailing Address - Street 2:
Mailing Address - City:WEIRTON
Mailing Address - State:WV
Mailing Address - Zip Code:26062-4124
Mailing Address - Country:US
Mailing Address - Phone:304-904-0095
Mailing Address - Fax:
Practice Address - Street 1:209 RITCHIE AVE # 411
Practice Address - Street 2:
Practice Address - City:WEIRTON
Practice Address - State:WV
Practice Address - Zip Code:26062-4124
Practice Address - Country:US
Practice Address - Phone:304-904-0095
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-10
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant