Provider Demographics
NPI:1780659920
Name:WATSON, ALEX BENTON (MD)
Entity Type:Individual
Prefix:DR
First Name:ALEX
Middle Name:BENTON
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 1:2315 8TH ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-7301
Mailing Address - Country:US
Mailing Address - Phone:208-746-1383
Mailing Address - Fax:208-746-6348
Practice Address - Street 1:2315 8TH ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-7301
Practice Address - Country:US
Practice Address - Phone:208-746-1383
Practice Address - Fax:208-746-6348
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2016-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003025568207V00000X
WAMD60171764207V00000X
IDM-11086207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00884051OtherRR MEDICARE
ID78464OtherBC/ID
ID1780659920Medicaid
ID1780659920OtherREGENCE BLUE SHIELD
WA2009820Medicaid
WA0267798OtherLABOR & INDUSTRIES
ID1780659920Medicaid
ID1196285Medicare PIN
WA0267798OtherLABOR & INDUSTRIES