Provider Demographics
NPI:1861645731
Name:WATSON, KRISTY LYNNE (OD)
Entity Type:Individual
Prefix:
First Name:KRISTY
Middle Name:LYNNE
Last Name:WATSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41215 E VILLAGE GREEN BLVD
Mailing Address - Street 2:APT 206
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-3886
Mailing Address - Country:US
Mailing Address - Phone:810-705-1757
Mailing Address - Fax:
Practice Address - Street 1:504 N TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48162-3337
Practice Address - Country:US
Practice Address - Phone:734-243-2020
Practice Address - Fax:734-243-4567
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-23
Last Update Date:2008-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004500152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist