Basic Information
| Provider Information | |||||||||
| NPI: | 1164606042 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WATSON | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 55 WHITCHER STREET | ||||||||
| Address2: | |||||||||
| City: | MAREITTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704284475 | ||||||||
| FaxNumber: | 7704284475 | ||||||||
| Practice Location | |||||||||
| Address1: | 55 WHITCHER STREET 250 | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704284475 | ||||||||
| FaxNumber: | 7704261499 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2007 | ||||||||
| LastUpdateDate: | 03/19/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 002739 | GA | N | Allopathic & Osteopathic Physicians | Surgery | 208800000X | 002739 | GA | N | Allopathic & Osteopathic Physicians | Urology | 208800000X | 0101250886 | VA | Y | Allopathic & Osteopathic Physicians | Urology |
No ID Information.