Provider Demographics
NPI:1770004392
Name:WATSON, BRANDON (OD)
Entity Type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:
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:PO BOX 783
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-0783
Mailing Address - Country:US
Mailing Address - Phone:509-689-2342
Mailing Address - Fax:509-689-9207
Practice Address - Street 1:123 HOSPITAL WAY
Practice Address - Street 2:
Practice Address - City:BREWSTER
Practice Address - State:WA
Practice Address - Zip Code:98812-0015
Practice Address - Country:US
Practice Address - Phone:509-689-2342
Practice Address - Fax:509-689-9207
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-05
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-100420152W00000X
COOPT.0003328152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000150236Medicaid