Healthcare Provider Details

I. General information

NPI: 1356418446
Provider Name (Legal Business Name): CARLA PATRICE WATSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 09/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

730 45TH AVE
MUNSTER IN
46321-2818
US

IV. Provider business mailing address

18660 GRAPHIC DR STE 100
TINLEY PARK IL
60477-6263
US

V. Phone/Fax

Practice location:
  • Phone: 219-934-2652
  • Fax: 219-934-2658
Mailing address:
  • Phone: 708-263-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number036106614
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: