Provider Demographics
NPI:1215068200
Name:WATCHMAN, GERALD L (LADAC)
Entity type:Individual
Prefix:
First Name:GERALD
Middle Name:L
Last Name:WATCHMAN
Suffix:
Gender:M
Credentials:LADAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 REDROCK DR
Mailing Address - Street 2:PFS DEPT
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-5683
Mailing Address - Country:US
Mailing Address - Phone:505-863-7000
Mailing Address - Fax:
Practice Address - Street 1:650 VANDEN BOSCH PKWY
Practice Address - Street 2:B
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-5508
Practice Address - Country:US
Practice Address - Phone:505-726-6900
Practice Address - Fax:505-722-6192
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM73141101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMVNM00011OTOtherVALUE OPTIONS