Provider Demographics
NPI:1760471908
Name:WATSON, DOUGLAS R (OD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:R
Last Name:WATSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 W MADISON ST
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:IL
Mailing Address - Zip Code:61764-1705
Mailing Address - Country:US
Mailing Address - Phone:815-844-2015
Mailing Address - Fax:815-844-4918
Practice Address - Street 1:301 W MADISON ST
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:IL
Practice Address - Zip Code:61764-1705
Practice Address - Country:US
Practice Address - Phone:815-844-2015
Practice Address - Fax:815-844-4918
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-20
Last Update Date:2009-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046007842152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046007842Medicaid
IL046007842Medicaid
IL1323090001Medicare NSC
T39057Medicare UPIN