Provider Demographics
NPI:1932172327
Name:WATSON, ROGER D (MD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:D
Last Name:WATSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:N17 W24100 RIVERWOOD DRIVE SUITE 250
Mailing Address - Street 2:PROHEALTH CARE MEDICAL ASSOCIATES INC.
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-1177
Mailing Address - Country:US
Mailing Address - Phone:262-928-4100
Mailing Address - Fax:262-928-5835
Practice Address - Street 1:2750 GOLF ROAD
Practice Address - Street 2:PROHEALTH CARE MEDICAL ASSOCIATES
Practice Address - City:DELAFIELD
Practice Address - State:WI
Practice Address - Zip Code:53018
Practice Address - Country:US
Practice Address - Phone:262-928-4900
Practice Address - Fax:262-928-4960
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2011-11-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI42990207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34349700Medicaid
WI004268070Medicare PIN
WI683750654Medicare PIN
WIH81633Medicare UPIN