Provider Demographics
NPI:1891768388
Name:WATANABE, WILSON T (MD)
Entity Type:Individual
Prefix:
First Name:WILSON
Middle Name:T
Last Name:WATANABE
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:PO BOX 371353
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89137-1353
Mailing Address - Country:US
Mailing Address - Phone:702-233-9222
Mailing Address - Fax:702-804-1349
Practice Address - Street 1:10300 W CHARLESTON BLVD STE 13-342
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89135-1037
Practice Address - Country:US
Practice Address - Phone:702-233-9222
Practice Address - Fax:702-804-1349
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2010-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV11156207R00000X, 207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV40496Medicare PIN
NVBZ427ZMedicare PIN
NVBZ427YMedicare PIN