Provider Demographics
NPI:1669413233
Name:WATSON, ROBERT
Entity type:Individual
Prefix:
First Name:ROBERT
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 1:5808 US HIGHWAY 11
Mailing Address - Street 2:
Mailing Address - City:PURVIS
Mailing Address - State:MS
Mailing Address - Zip Code:39475-5052
Mailing Address - Country:US
Mailing Address - Phone:601-348-5460
Mailing Address - Fax:601-348-1432
Practice Address - Street 1:5808 US HIGHWAY 11
Practice Address - Street 2:
Practice Address - City:PURVIS
Practice Address - State:MS
Practice Address - Zip Code:39475
Practice Address - Country:US
Practice Address - Phone:601-348-5460
Practice Address - Fax:601-348-1432
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS15187207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine