Healthcare Provider Details

I. General information

NPI: 1548554157
Provider Name (Legal Business Name): MARK ADAM WATSON D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2011
Last Update Date: 01/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3231 EUCLID AVE 5TH FLOOR
BERWYN IL
60402-3471
US

IV. Provider business mailing address

3231 EUCLID AVE 5TH FLOOR
BERWYN IL
60402-3471
US

V. Phone/Fax

Practice location:
  • Phone: 708-783-2000
  • Fax: 708-783-3656
Mailing address:
  • Phone: 708-783-2000
  • Fax: 708-783-3656

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number125-059143
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: