Provider Demographics
NPI:1104930874
Name:WATSON, KANDRA W (MD)
Entity type:Individual
Prefix:
First Name:KANDRA
Middle Name:W
Last Name:WATSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P O BOX 84052
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31908-4052
Mailing Address - Country:US
Mailing Address - Phone:706-332-7884
Mailing Address - Fax:706-243-4358
Practice Address - Street 1:610 19TH ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31901-1528
Practice Address - Country:US
Practice Address - Phone:706-332-7884
Practice Address - Fax:706-243-4356
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA064988207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003101384BMedicaid
GA600-62186OtherBCBSAL
GA000310384CMedicaid
GA000310384AMedicaid
GA003101384BMedicaid