=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194866046
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELEANOR A WATSON MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/12/2007
-----------------------------------------------------
Last Update Date | 11/24/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1600 W GRAND RIVER AVE STE 2
-----------------------------------------------------
City | OKEMOS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48864-2394
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-349-6560
-----------------------------------------------------
Fax | 517-349-5796
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 804 SERVICE RD STE A202
-----------------------------------------------------
City | EAST LANSING
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48824-7015
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-349-6560
-----------------------------------------------------
Fax | 517-349-5796
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 4301083120
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------