Healthcare Provider Details

I. General information

NPI: 1487920484
Provider Name (Legal Business Name): SUTTHISRI WATSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2012
Last Update Date: 03/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 ALTA VISTA AVE
LOS ALTOS CA
94022-2101
US

IV. Provider business mailing address

150 ALTA VISTA AVE
LOS ALTOS CA
94022-2101
US

V. Phone/Fax

Practice location:
  • Phone: 650-303-4090
  • Fax:
Mailing address:
  • Phone: 650-303-4090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA37853
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: