Provider Demographics
NPI:1700144417
Name:WATANABE, WILSON TATSUO (MD)
Entity Type:Individual
Prefix:
First Name:WILSON
Middle Name:TATSUO
Last Name:WATANABE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 CHESTER PARK CIR
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:SC
Mailing Address - Zip Code:29709-1009
Mailing Address - Country:US
Mailing Address - Phone:843-623-2687
Mailing Address - Fax:
Practice Address - Street 1:122 CHESTER PARK CIR
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:SC
Practice Address - Zip Code:29709-1009
Practice Address - Country:US
Practice Address - Phone:843-623-2687
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-01
Last Update Date:2012-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD6441207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery