Basic Information
| Provider Information | |||||||||
| NPI: | 1114905221 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WATSON | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14275 MIDWAY RD | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | ADDISON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750013614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2149328029 | ||||||||
| FaxNumber: | 6102714245 | ||||||||
| Practice Location | |||||||||
| Address1: | 10330 HICKMAN MILLS DR | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641371618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8164127004 | ||||||||
| FaxNumber: | 8167637536 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2006 | ||||||||
| LastUpdateDate: | 11/26/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | R8692 | MO | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZP0102X | 20A9489 | CA | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 241950005 | 05 | KS | MEDICAID | 100229790A | 05 | KS | MEDICAID |