Provider Demographics
NPI:1851309199
Name:WATSON, DAVID MICHAEL (OD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:MICHAEL
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 1:3891 RIVERPARK AVE
Mailing Address - Street 2:
Mailing Address - City:ONA
Mailing Address - State:WV
Mailing Address - Zip Code:25545
Mailing Address - Country:US
Mailing Address - Phone:304-546-5870
Mailing Address - Fax:
Practice Address - Street 1:1330 N EISENHOWER DR
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801
Practice Address - Country:US
Practice Address - Phone:304-250-0336
Practice Address - Fax:304-250-0339
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV6690152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0150535000Medicaid
WV0150535000Medicaid