Healthcare Provider Details

I. General information

NPI: 1134700511
Provider Name (Legal Business Name): JEREMY BRUCE WATSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2021
Last Update Date: 04/19/2021
Certification Date: 04/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2201 HEMPSTEAD TPKE
EAST MEADOW NY
11554-1859
US

IV. Provider business mailing address

2201 HEMPSTEAD TPKE
EAST MEADOW NY
11554-1859
US

V. Phone/Fax

Practice location:
  • Phone: 516-572-0123
  • Fax:
Mailing address:
  • Phone: 205-826-4235
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: