Provider Demographics
NPI:1962472886
Name:WATSON, RICHARD O (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:O
Last Name:WATSON
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 786
Mailing Address - Street 2:
Mailing Address - City:FLOSSMOOR
Mailing Address - State:IL
Mailing Address - Zip Code:60422-0786
Mailing Address - Country:US
Mailing Address - Phone:312-206-1064
Mailing Address - Fax:708-991-2630
Practice Address - Street 1:30 E 15TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60411
Practice Address - Country:US
Practice Address - Phone:312-206-1064
Practice Address - Fax:708-991-2630
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-24
Last Update Date:2018-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.102951207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200334030Medicaid
IN930118931OtherMEDICARE RAILROAD
IL90001082OtherBCBS
IN000000223689OtherANTHEM BCBS
IN189880CMedicare ID - Type Unspecified
IL90001082OtherBCBS