Provider Demographics
NPI:1730114968
Name:WATSON, TIMOTHY (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:WATSON
Suffix:
Gender:M
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:PO BOX 9270
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92375-2470
Mailing Address - Country:US
Mailing Address - Phone:951-779-1670
Mailing Address - Fax:951-779-1679
Practice Address - Street 1:6926 BROCKTON AVE STE 6
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-3804
Practice Address - Country:US
Practice Address - Phone:951-779-1670
Practice Address - Fax:951-779-1679
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA79382208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0095040Medicaid
CA00A793820Medicare ID - Type Unspecified
CAGR0095040Medicaid