Provider Demographics
NPI:1265735062
Name:KEITH A WATSON MD INC
Entity type:Organization
Organization Name:KEITH A WATSON MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:A
Authorized Official - Last Name:WATSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:937-767-7311
Mailing Address - Street 1:100 KAHOE LN
Mailing Address - Street 2:
Mailing Address - City:YELLOW SPRINGS
Mailing Address - State:OH
Mailing Address - Zip Code:45387-1243
Mailing Address - Country:US
Mailing Address - Phone:937-767-7311
Mailing Address - Fax:
Practice Address - Street 1:100 KAHOE LN
Practice Address - Street 2:
Practice Address - City:YELLOW SPRINGS
Practice Address - State:OH
Practice Address - Zip Code:45387-1243
Practice Address - Country:US
Practice Address - Phone:937-767-7311
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-16
Last Update Date:2011-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35043758207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0496780Medicaid
OH0496780Medicaid
OH0514791Medicare PIN