Healthcare Provider Details

I. General information

NPI: 1881906022
Provider Name (Legal Business Name): SAMUEL JACOB WATSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2010
Last Update Date: 03/13/2023
Certification Date: 03/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1640 BRYAN STATION RD STE 1
LEXINGTON KY
40505-2144
US

IV. Provider business mailing address

496 SOUTHLAND DR
LEXINGTON KY
40503-1827
US

V. Phone/Fax

Practice location:
  • Phone: 859-288-2425
  • Fax: 859-721-3918
Mailing address:
  • Phone: 859-288-2392
  • Fax: 859-721-3918

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number46559
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: