MEDICARE: JACQUELYN R WATSON MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0001X	Radiation Oncology Physician	404424	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0C96059	OTHER	MI	BCBSM
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1801881065
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELYN R WATSON MD

Provider Business Mailing Address
First Line	:	601 JOHN ST
Second Line	:	BOX 42
City	:	KALAMAZOO
State	:	MI
Zip	:	49007-5341
Country	:	US
Telephone Number	:	269-341-7806
Fax Number	:	269-341-8743

Provider Business Practice Location Address
First Line	:	200 N PARK ST
Second Line	:	WEST MICHIGAN CANCER CENTER
City	:	KALAMAZOO
State	:	MI
Zip	:	49007-3731
Country	:	US
Telephone Number	:	269-373-7474
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/14/2005
Last Update Date	:	09/21/2009

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