Provider Demographics
NPI:1770581167
Name:HARRIS-WATSON, BRENDA LUCILLE (MD)
Entity type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:LUCILLE
Last Name:HARRIS-WATSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MISS
Other - First Name:BRENDA
Other - Middle Name:LUCILLE
Other - Last Name:HARRIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1801 LEE RD STE 165
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789-2127
Mailing Address - Country:US
Mailing Address - Phone:407-975-0406
Mailing Address - Fax:407-975-0407
Practice Address - Street 1:400 CELEBRATION PL
Practice Address - Street 2:
Practice Address - City:CELEBRATION
Practice Address - State:FL
Practice Address - Zip Code:34747
Practice Address - Country:US
Practice Address - Phone:407-975-0406
Practice Address - Fax:407-975-0407
Is Sole Proprietor?:No
Enumeration Date:2005-07-11
Last Update Date:2018-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME93727207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL252838000Medicaid
B47809Medicare UPIN
FL252838000Medicaid