Provider Demographics
NPI:1356418446
Name:WATSON, CARLA PATRICE (MD)
Entity type:Individual
Prefix:
First Name:CARLA
Middle Name:PATRICE
Last Name:WATSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18660 GRAPHIC DR
Mailing Address - Street 2:STE 100
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477-6263
Mailing Address - Country:US
Mailing Address - Phone:708-263-2000
Mailing Address - Fax:
Practice Address - Street 1:730 45TH AVE
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-2818
Practice Address - Country:US
Practice Address - Phone:219-934-2652
Practice Address - Fax:219-934-2658
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2017-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036106614225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL363236791OtherTAX ID #
IL036106614Medicaid
IL036106614Medicaid
IL363236791OtherTAX ID #
ILH73723Medicare UPIN