Provider Demographics
NPI:1700986858
Name:WATSON, JACK R (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:R
Last Name:WATSON
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 1:550 WATER ST STE A
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-4126
Mailing Address - Country:US
Mailing Address - Phone:831-425-0420
Mailing Address - Fax:831-425-0185
Practice Address - Street 1:550 WATER ST STE A
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-4126
Practice Address - Country:US
Practice Address - Phone:831-425-0420
Practice Address - Fax:831-425-0185
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA65310207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A653100Medicaid
CAGR0100850Medicaid
CA00A653102Medicare PIN
CAGR0100850Medicaid
CAZZZ02797ZMedicare PIN
CA00A653100Medicare PIN