Healthcare Provider Details

I. General information

NPI: 1124166574
Provider Name (Legal Business Name): WATSON CLINIC LLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2007
Last Update Date: 03/01/2024
Certification Date: 03/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1033 N PARKWAY FRONTAGE RD
LAKELAND FL
33803-0401
US

IV. Provider business mailing address

1600 LAKELAND HILLS BLVD
LAKELAND FL
33805-3019
US

V. Phone/Fax

Practice location:
  • Phone: 863-647-8011
  • Fax:
Mailing address:
  • Phone: 863-680-7000
  • Fax: 866-264-8519

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. JASON HIRSBRUNNER
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 863-680-7007