Basic Information
| Provider Information | |||||||||
| NPI: | 1376573964 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WATSON | ||||||||
| FirstName: | PEGGY | ||||||||
| MiddleName: | HALLETT | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3702 NEW VISION DR | ||||||||
| Address2: | BLDG B | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468451703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4196364517 | ||||||||
| FaxNumber: | 4196366438 | ||||||||
| Practice Location | |||||||||
| Address1: | 935 E SNYDER AVE | ||||||||
| Address2: | |||||||||
| City: | MONTPELIER | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435431251 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4194856509 | ||||||||
| FaxNumber: | 4194858776 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2006 | ||||||||
| LastUpdateDate: | 12/06/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 35-077468 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2199357 | 05 | OH | MEDICAID | 080160917 | 01 | OH | RAILROAD | OTHER |