Provider Demographics
NPI:1134448418
Name:WATSON, RICHARD
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:WATSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 SE COVENANT DR
Mailing Address - Street 2:
Mailing Address - City:GRIMES
Mailing Address - State:IA
Mailing Address - Zip Code:50111-4891
Mailing Address - Country:US
Mailing Address - Phone:515-314-9353
Mailing Address - Fax:
Practice Address - Street 1:2400 SE COVENANT DR
Practice Address - Street 2:
Practice Address - City:GRIMES
Practice Address - State:IA
Practice Address - Zip Code:50111-4891
Practice Address - Country:US
Practice Address - Phone:515-314-9353
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-26
Last Update Date:2010-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA27-2674804332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA37311Medicaid
IA37311Medicaid
IA3731150322Medicare PIN
IA3731150312Medicare Oscar/Certification
IA3731150111Medicare NSC