Provider Demographics
NPI:1679524599
Name:WATSON, WILLIAM C (DO)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:C
Last Name:WATSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:W.
Other - Middle Name:CHRIS
Other - Last Name:WATSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:217 W 27TH ST
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55408-1504
Mailing Address - Country:US
Mailing Address - Phone:612-203-9812
Mailing Address - Fax:
Practice Address - Street 1:217 W 27TH ST
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55408-1504
Practice Address - Country:US
Practice Address - Phone:612-203-9812
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2017-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI45162207Q00000X, 207QA0505X
MN58489207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIB57487Medicare UPIN