Provider Demographics
NPI:1053615641
Name:NANCY M WATSON MD PC
Entity type:Organization
Organization Name:NANCY M WATSON MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:
Authorized Official - Last Name:WATSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-754-8884
Mailing Address - Street 1:PO BOX 1718
Mailing Address - Street 2:
Mailing Address - City:DEMOREST
Mailing Address - State:GA
Mailing Address - Zip Code:30535-1718
Mailing Address - Country:US
Mailing Address - Phone:706-754-8884
Mailing Address - Fax:
Practice Address - Street 1:676 441 HISTORIC HWY N
Practice Address - Street 2:
Practice Address - City:DEMOREST
Practice Address - State:GA
Practice Address - Zip Code:30535-4523
Practice Address - Country:US
Practice Address - Phone:706-754-8884
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-22
Last Update Date:2010-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA042766207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000718121AMedicaid
GA000718121AMedicaid