Provider Demographics
NPI:1124421359
Name:WATSON, MICHAEL DALLAS (MS)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DALLAS
Last Name:WATSON
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4952 W LIBERTY PARK CIR
Mailing Address - Street 2:
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29405-4009
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12575 US HIGHWAY 1
Practice Address - Street 2:STE 200
Practice Address - City:JUNO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33408-2477
Practice Address - Country:US
Practice Address - Phone:561-284-7899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-02
Last Update Date:2014-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY999999999171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC999999999OtherTEST