Healthcare Provider Details

I. General information

NPI: 1730114968
Provider Name (Legal Business Name): TIMOTHY WATSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 02/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6926 BROCKTON AVE STE 6
RIVERSIDE CA
92506-3804
US

IV. Provider business mailing address

PO BOX 9270
REDLANDS CA
92375-2470
US

V. Phone/Fax

Practice location:
  • Phone: 951-779-1670
  • Fax: 951-779-1679
Mailing address:
  • Phone: 951-779-1670
  • Fax: 951-779-1679

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA79382
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: