Basic Information
| Provider Information | |||||||||
| NPI: | 1871541235 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WATSON | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5477 IRELAND RD | ||||||||
| Address2: | |||||||||
| City: | COOLVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 457239484 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7406673088 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2610 CAMDEN AVE | ||||||||
| Address2: | |||||||||
| City: | PARKERSBURG | ||||||||
| State: | WV | ||||||||
| PostalCode: | 261015652 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3049173733 | ||||||||
| FaxNumber: | 3049173750 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2006 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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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 | 207Q00000X | 35-07-0544 | OH | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 18452 | WV | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0194883 | 05 | OH | MEDICAID | 000443574 | 01 | BLUE CROSS/BLUE SHIELD | OTHER | 080119030 | 01 | RAILROAD MEDICARE | OTHER | 0054468000 | 05 | WV | MEDICAID |