Healthcare Provider Details

I. General information

NPI: 1215936323
Provider Name (Legal Business Name): RAQUEL MARIA WATSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2005
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5300 MEMORIAL DR STE 121
STONE MOUNTAIN GA
30083-3154
US

IV. Provider business mailing address

142 WATERS EDGE DR
LIZELLA GA
31052-3629
US

V. Phone/Fax

Practice location:
  • Phone: 404-254-4500
  • Fax: 404-254-4517
Mailing address:
  • Phone: 478-744-9920
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number032674
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number032674
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: