=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306830898
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BONNIE L MCDONALD WATSON DO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/10/2005
-----------------------------------------------------
Last Update Date | 10/10/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18555 N 79TH AVE STE B108
-----------------------------------------------------
City | GLENDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85308-8372
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-773-2848
-----------------------------------------------------
Fax | 623-773-0370
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18555 N 79TH AVE B 108
-----------------------------------------------------
City | GLENDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85308-8370
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-773-2848
-----------------------------------------------------
Fax | 623-773-0370
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 4135
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------