Healthcare Provider Details

I. General information

NPI: 1760748008
Provider Name (Legal Business Name): JUSTIN J WATSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2012
Last Update Date: 11/02/2023
Certification Date: 11/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2119 REGENT ST
MADISON WI
53726-3941
US

IV. Provider business mailing address

2119 REGENT ST
MADISON WI
53726-3941
US

V. Phone/Fax

Practice location:
  • Phone: 360-305-4988
  • Fax:
Mailing address:
  • Phone: 360-305-4988
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204F00000X
TaxonomyTransplant Surgery Physician
License Number73952
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberMED-PHYS-LIC-127761
License Number StateMT
# 3
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number73952
License Number StateWI
# 4
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number127761
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: