Basic Information
| Provider Information | |||||||||
| NPI: | 1356791628 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WATSON | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | ROBERT | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1123 BARDIC CIR | ||||||||
| Address2: | |||||||||
| City: | SAINT PETERS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633767670 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4123357286 | ||||||||
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| Practice Location | |||||||||
| Address1: | 463 LYNN HAVEN LN | ||||||||
| Address2: | |||||||||
| City: | HAZELWOOD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630421808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3147310448 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2016 | ||||||||
| LastUpdateDate: | 06/17/2016 | ||||||||
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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 | 225100000X | 2016020586 | MO | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.