Healthcare Provider Details

I. General information

NPI: 1043841448
Provider Name (Legal Business Name): COLIN MAHLON WATSON PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/04/2020
Last Update Date: 02/04/2020
Certification Date: 02/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5040 FOREST DR STE 300
NEW ALBANY OH
43054-8166
US

IV. Provider business mailing address

70 S CLEVELAND AVE
WESTERVILLE OH
43081-1397
US

V. Phone/Fax

Practice location:
  • Phone: 614-890-6555
  • Fax:
Mailing address:
  • Phone: 614-839-2115
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.006318RX
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: