Provider Demographics
NPI:1801036934
Name:WATSON, ANDREA (MD)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:WATSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:
Other - Last Name:DIOMANDE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1700 RING RD
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-9497
Mailing Address - Country:US
Mailing Address - Phone:270-769-5551
Mailing Address - Fax:270-982-2128
Practice Address - Street 1:1111 RING RD
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-4900
Practice Address - Country:US
Practice Address - Phone:270-706-1925
Practice Address - Fax:270-706-1926
Is Sole Proprietor?:No
Enumeration Date:2009-03-02
Last Update Date:2012-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY44759207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100164040Medicaid
KY7100164040Medicaid