Basic Information
| Provider Information | |||||||||
| NPI: | 1952415663 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WATSON | ||||||||
| FirstName: | CLYDE | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5900 LONG MEADOW DR | ||||||||
| Address2: | |||||||||
| City: | MIDDLETOWN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450059687 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5134203773 | ||||||||
| FaxNumber: | 5137272539 | ||||||||
| Practice Location | |||||||||
| Address1: | 5900 LONG MEADOW DR | ||||||||
| Address2: | |||||||||
| City: | MIDDLETOWN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450059687 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5134203773 | ||||||||
| FaxNumber: | 5137272539 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2006 | ||||||||
| LastUpdateDate: | 08/12/2015 | ||||||||
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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 | 207P00000X | 35038821 | NC | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | 35.038821 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207P00000X | 35.038821 | OH | N | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0296595 | 05 | OH | MEDICAID | P00193943 | 01 | RR MCR | OTHER | 000000032022 | 01 | BCBS | OTHER |