Basic Information
| Provider Information | |||||||||
| NPI: | 1427122282 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WATSON | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | BRUCE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 107 E BURKE AVE | ||||||||
| Address2: | |||||||||
| City: | TOWSON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212861118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4108288113 | ||||||||
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| Practice Location | |||||||||
| Address1: | 201 E UNIVERSITY PKWY | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212182829 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105542107 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2006 | ||||||||
| LastUpdateDate: | 02/29/2008 | ||||||||
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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 | 207P00000X | D54594 | MD | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | MD31689 | DC | N | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 75859901 | 01 | MD | BLUE SHIELD | OTHER | 75859903 | 01 | MD | BLUE SHIELD | OTHER | 0010142 | 05 | MS | MEDICAID |