Basic Information
| Provider Information | |||||||||
| NPI: | 1881906022 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WATSON | ||||||||
| FirstName: | SAMUEL | ||||||||
| MiddleName: | JACOB | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 496 SOUTHLAND DR | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405031827 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592882392 | ||||||||
| FaxNumber: | 8597213918 | ||||||||
| Practice Location | |||||||||
| Address1: | 1640 BRYAN STATION RD STE 1 | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405052144 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592882425 | ||||||||
| FaxNumber: | 8597213918 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2010 | ||||||||
| LastUpdateDate: | 05/20/2019 | ||||||||
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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 | 208000000X | 46559 | KY | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 7100253290 | 05 | KY | MEDICAID | 46559 | 01 | KY | KENTUCKY BOARD OF MEDICAL LICENSURE | OTHER |