Provider Demographics
NPI:1740395383
Name:WATSON, TERRENCE A (MD)
Entity Type:Individual
Prefix:DR
First Name:TERRENCE
Middle Name:A
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 1:1234 E DUPONT RD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1545
Mailing Address - Country:US
Mailing Address - Phone:260-373-9965
Mailing Address - Fax:260-373-9740
Practice Address - Street 1:2708 GUILFORD ST
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:IN
Practice Address - Zip Code:46750-9701
Practice Address - Country:US
Practice Address - Phone:260-355-3900
Practice Address - Fax:260-355-3079
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2012-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01038558A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP00698423OtherMEDICARE RR
IN000000595593OtherANTHEM
IN100369330Medicaid
INF30420Medicare UPIN
IN055250NMedicare ID - Type Unspecified
IN100369330Medicaid
IN259060SMedicare PIN