Provider Demographics
NPI:1528089786
Name:STEPHEN D. WATSON, M.D., PHD., INC.
Entity type:Organization
Organization Name:STEPHEN D. WATSON, M.D., PHD., INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BILLING / OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:LEDBETTER
Authorized Official - Suffix:
Authorized Official - Credentials:CMAA, CPC
Authorized Official - Phone:937-323-3900
Mailing Address - Street 1:2816 W 1ST ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45504-4264
Mailing Address - Country:US
Mailing Address - Phone:937-323-3900
Mailing Address - Fax:937-398-0329
Practice Address - Street 1:2816 W 1ST ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45504-4264
Practice Address - Country:US
Practice Address - Phone:937-323-3900
Practice Address - Fax:937-398-0329
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35063329W174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2106385Medicaid
OH2106385Medicaid
OH9304671Medicare ID - Type UnspecifiedGROUP #