Provider Demographics
NPI:1164524005
Name:WATSON, STANLEY RUDOLPH (MD)
Entity type:Individual
Prefix:DR
First Name:STANLEY
Middle Name:RUDOLPH
Last Name:WATSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 96860
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28296-6860
Mailing Address - Country:US
Mailing Address - Phone:919-359-1011
Mailing Address - Fax:919-359-9122
Practice Address - Street 1:864 BLACK CREEK RD
Practice Address - Street 2:
Practice Address - City:FOUR OAKS
Practice Address - State:NC
Practice Address - Zip Code:27524-8314
Practice Address - Country:US
Practice Address - Phone:919-963-3148
Practice Address - Fax:919-963-2900
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2025-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC38490207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8985994Medicaid
NC080063193OtherRAILROAD MEDICARE
NC2161730DMedicare ID - Type Unspecified
NC8985994Medicaid