Provider Demographics
NPI:1962474031
Name:WATSON, MARY E (M D)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:WATSON
Suffix:
Gender:F
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 E 20TH ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105-1013
Mailing Address - Country:US
Mailing Address - Phone:605-575-1616
Mailing Address - Fax:605-367-7157
Practice Address - Street 1:1115 E 20TH ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-1013
Practice Address - Country:US
Practice Address - Phone:605-575-1616
Practice Address - Fax:605-367-7157
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2008-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1982207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN777868600Medicaid
SD5607050Medicaid
SDS6919Medicare PIN
MN777868600Medicaid