Provider Demographics
NPI:1770676793
Name:WATSON, GREGORY L (DO)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:L
Last Name:WATSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1490 E FOREMASTER DR STE 200
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-4496
Mailing Address - Country:US
Mailing Address - Phone:435-628-1641
Mailing Address - Fax:435-628-1660
Practice Address - Street 1:1490 E FOREMASTER DR STE 200
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-4496
Practice Address - Country:US
Practice Address - Phone:435-628-1641
Practice Address - Fax:435-628-1660
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2013-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT53232691204208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTH20447Medicare UPIN
UT0055399904Medicare ID - Type Unspecified