Basic Information
| Provider Information | |||||||||
| NPI: | 1386623817 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WATSON | ||||||||
| FirstName: | KEITH | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 KAHOE LN | ||||||||
| Address2: | |||||||||
| City: | YELLOW SPRINGS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453871243 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9377677311 | ||||||||
| FaxNumber: | 9377677107 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 KAHOE LN | ||||||||
| Address2: | |||||||||
| City: | YELLOW SPRINGS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453871243 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9377677311 | ||||||||
| FaxNumber: | 9377677107 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2006 | ||||||||
| LastUpdateDate: | 09/28/2011 | ||||||||
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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 | 207V00000X | 35-04-3758-W | OH | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 0496780 | 05 | OH | MEDICAID | 160038944 | 01 | OH | R/R MEDICARE PIN | OTHER | 311144553026 | 01 | OH | CARESOURCE PIN | OTHER |