Healthcare Provider Details

I. General information

NPI: 1720320658
Provider Name (Legal Business Name): MATTHEW ROBERT WATSON D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/18/2013
Last Update Date: 04/19/2023
Certification Date: 04/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1711 27TH ST STE 206
PORTSMOUTH OH
45662-2669
US

IV. Provider business mailing address

1735 27TH ST STE B06
PORTSMOUTH OH
45662-2681
US

V. Phone/Fax

Practice location:
  • Phone: 740-356-8772
  • Fax: 740-356-1264
Mailing address:
  • Phone: 740-356-8681
  • Fax: 740-356-1256

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number02004692A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number34.014050
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: