Basic Information
| Provider Information | |||||||||
| NPI: | 1780659920 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WATSON | ||||||||
| FirstName: | ALEX | ||||||||
| MiddleName: | BENTON | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2315 8TH ST | ||||||||
| Address2: | |||||||||
| City: | LEWISTON | ||||||||
| State: | ID | ||||||||
| PostalCode: | 835017301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087461383 | ||||||||
| FaxNumber: | 2087466348 | ||||||||
| Practice Location | |||||||||
| Address1: | 2315 8TH ST | ||||||||
| Address2: | |||||||||
| City: | LEWISTON | ||||||||
| State: | ID | ||||||||
| PostalCode: | 835017301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087461383 | ||||||||
| FaxNumber: | 2087466348 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2006 | ||||||||
| LastUpdateDate: | 03/07/2016 | ||||||||
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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 | 207V00000X | 2003025568 | MO | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207V00000X | MD60171764 | WA | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207V00000X | M-11086 | ID | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | P00884051 | 01 | IL | RR MEDICARE | OTHER | 78464 | 01 | ID | BC/ID | OTHER | 1780659920 | 05 | ID | MEDICAID | 1780659920 | 01 | ID | REGENCE BLUE SHIELD | OTHER | 2009820 | 05 | WA | MEDICAID | 0267798 | 01 | WA | LABOR & INDUSTRIES | OTHER |