Healthcare Provider Details

I. General information

NPI: 1417914516
Provider Name (Legal Business Name): JASON LEE WATSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2006
Last Update Date: 01/31/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

133 N HOWARD AVE
LANDRUM SC
29356-1507
US

IV. Provider business mailing address

PO BOX 2168
SPARTANBURG SC
29304-2168
US

V. Phone/Fax

Practice location:
  • Phone: 864-457-3838
  • Fax: 864-560-9532
Mailing address:
  • Phone: 864-560-4304
  • Fax: 864-560-4413

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberTL30486
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: