Provider Demographics
NPI:1891984274
Name:CAROL L WATSON MD LLC
Entity Type:Organization
Organization Name:CAROL L WATSON MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:L
Authorized Official - Last Name:BOUCHARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-749-4416
Mailing Address - Street 1:140 HAZARD AVE
Mailing Address - Street 2:SUITE 107
Mailing Address - City:ENFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06082-4520
Mailing Address - Country:US
Mailing Address - Phone:860-749-4416
Mailing Address - Fax:860-749-4506
Practice Address - Street 1:140 HAZARD AVENUE
Practice Address - Street 2:SUITE 107
Practice Address - City:ENFIELD
Practice Address - State:CT
Practice Address - Zip Code:06082-4520
Practice Address - Country:US
Practice Address - Phone:860-749-4416
Practice Address - Fax:860-749-4506
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-22
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT042373207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT00142370Medicaid