Healthcare Provider Details

I. General information

NPI: 1376170274
Provider Name (Legal Business Name): WATSON RETINA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2020
Last Update Date: 04/11/2022
Certification Date: 04/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4505 PINE TREE CIR STE 120
VESTAVIA AL
35243-2380
US

IV. Provider business mailing address

4505 PINE TREE CIR STE 120
VESTAVIA AL
35243-2380
US

V. Phone/Fax

Practice location:
  • Phone: 205-637-7123
  • Fax:
Mailing address:
  • Phone: 205-637-7123
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number
License Number State

VIII. Authorized Official

Name: RICHARD WATSON
Title or Position: MD
Credential:
Phone: 205-637-7123