Provider Demographics
NPI:1760748008
Name:WATSON, JUSTIN J (MD)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:J
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 1:2119 REGENT ST
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53726-3941
Mailing Address - Country:US
Mailing Address - Phone:360-305-4988
Mailing Address - Fax:
Practice Address - Street 1:2119 REGENT ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53726-3941
Practice Address - Country:US
Practice Address - Phone:360-305-4988
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-11
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI73952204F00000X, 208G00000X
MTMED-PHYS-LIC-127761207RC0000X
MT127761208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No204F00000XAllopathic & Osteopathic PhysiciansTransplant Surgery
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100180924Medicaid