Healthcare Provider Details

I. General information

NPI: 1780659920
Provider Name (Legal Business Name): ALEX BENTON WATSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2006
Last Update Date: 03/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2315 8TH ST
LEWISTON ID
83501-7301
US

IV. Provider business mailing address

2315 8TH ST
LEWISTON ID
83501-7301
US

V. Phone/Fax

Practice location:
  • Phone: 208-746-1383
  • Fax: 208-746-6348
Mailing address:
  • Phone: 208-746-1383
  • Fax: 208-746-6348

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number2003025568
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberMD60171764
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberM-11086
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: