Provider Demographics
NPI:1003926049
Name:WATSON, STACEY
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:WATSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 SHAFFER STREET
Mailing Address - Street 2:SUITE 002
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49048
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:269-552-2964
Practice Address - Street 1:8450 N 32ND ST
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:MI
Practice Address - Zip Code:49083-9418
Practice Address - Country:US
Practice Address - Phone:269-226-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301068288207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G95443Medicare UPIN