Provider Demographics
NPI:1720076847
Name:WATSON, TERRY (DO,PA)
Entity Type:Individual
Prefix:DR
First Name:TERRY
Middle Name:
Last Name:WATSON
Suffix:
Gender:M
Credentials:DO,PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7920 ELMBROOK DR STE 108
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75247-4933
Mailing Address - Country:US
Mailing Address - Phone:214-221-8181
Mailing Address - Fax:214-221-8282
Practice Address - Street 1:7920 ELMBROOK DR STE 108
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75247
Practice Address - Country:US
Practice Address - Phone:214-221-8181
Practice Address - Fax:214-221-8282
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-12
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF3376208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP000JK198Medicaid
TX00JK19Medicare ID - Type Unspecified
B27433Medicare UPIN