Basic Information
| Provider Information | |||||||||
| NPI: | 1881768653 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WATSON | ||||||||
| FirstName: | LUKE | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5856 CORPORATE AVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | CYPRESS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7142364000 | ||||||||
| FaxNumber: | 7142364006 | ||||||||
| Practice Location | |||||||||
| Address1: | 2776 PACIFIC AVE | ||||||||
| Address2: | |||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5629972232 | ||||||||
| FaxNumber: | 5629972238 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 207ZP0102X | G60383 | CA | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 00G603830 | 05 | CA | MEDICAID |