Healthcare Provider Details

I. General information

NPI: 1487653655
Provider Name (Legal Business Name): RANDY CHARLES WATSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/19/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 ELKS POINT ROAD SUITE 200
ZEPHYR COVE NV
89448
US

IV. Provider business mailing address

PO BOX 11889
ZEPHYR COVE NV
89448-3889
US

V. Phone/Fax

Practice location:
  • Phone: 775-588-3636
  • Fax: 775-588-1299
Mailing address:
  • Phone: 775-588-3636
  • Fax: 775-588-1299

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number3188
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: