MEDICARE: WILSON T WATANABE MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	11156	NV
2	207RC0200X	Critical Care Medicine (Internal Medicine) Physician	11156	NV
3	207RP1001X	Pulmonary Disease Physician	11156	NV

General Provider Information

NPI Number	:	1891768388
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WILSON T WATANABE MD

Provider Business Mailing Address
First Line	:	PO BOX 371353
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89137-1353
Country	:	US
Telephone Number	:	702-233-9222
Fax Number	:	702-804-1349

Provider Business Practice Location Address
First Line	:	10300 W CHARLESTON BLVD STE 13-342
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89135-1037
Country	:	US
Telephone Number	:	702-233-9222
Fax Number	:	702-804-1349

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/07/2006
Last Update Date	:	04/13/2010

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