Basic Information
| Provider Information | |||||||||
| NPI: | 1427307164 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WATSON | ||||||||
| FirstName: | CARLA | ||||||||
| MiddleName: | RAYCHELLE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BRYANT | ||||||||
| OtherFirstName: | CARLA | ||||||||
| OtherMiddleName: | RAYCHELLE | ||||||||
| OtherNamePrefix: | MS. | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4201 ST. ANTOINE UHC 5D # 226 | ||||||||
| Address2: | UNIVERSITY PEDIATRICIANS | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3139665051 | ||||||||
| FaxNumber: | 3139660665 | ||||||||
| Practice Location | |||||||||
| Address1: | CHILDREN'S HOSPITAL OF MI/SPECIALTY CENTER | ||||||||
| Address2: | 3950 BEAUBIEN GROUND FLOOR, GARDEN LEVEL | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3137455437 | ||||||||
| FaxNumber: | 3137450955 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2012 | ||||||||
| LastUpdateDate: | 08/07/2017 | ||||||||
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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 | 208000000X | 4301101320 | MI | N | Allopathic & Osteopathic Physicians | Pediatrics | 2084N0402X | 4301101320 | MI | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology with Special Qualifications in Child Neurology |
No ID Information.