Provider Demographics
NPI:1942695473
Name:WATSON, BRUCE ALLEN (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:ALLEN
Last Name:WATSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1789
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24008-1789
Mailing Address - Country:US
Mailing Address - Phone:540-855-5139
Mailing Address - Fax:540-342-4373
Practice Address - Street 1:2802 BRANDON AVE SW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24015-3310
Practice Address - Country:US
Practice Address - Phone:540-855-5139
Practice Address - Fax:540-342-4373
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-01
Last Update Date:2015-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101025426207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology