Provider Demographics
NPI:1194795948
Name:WATSON, KEITH
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:WATSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1475 WESTERN AVE
Mailing Address - Street 2:STE 51 #38008
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12203-3520
Mailing Address - Country:US
Mailing Address - Phone:518-217-6008
Mailing Address - Fax:182-176-0045
Practice Address - Street 1:141 WASHINGTON AVENUE EXT
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12205-5609
Practice Address - Country:US
Practice Address - Phone:518-217-6008
Practice Address - Fax:518-217-6004
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2022-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV009274152WP0200X, 152WC0802X, 152W00000X
CT2588152WP0200X, 152WV0400X, 152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY06488393Medicaid