Provider Demographics
NPI:1215936323
Name:WATSON, RAQUEL MARIA (MD)
Entity type:Individual
Prefix:DR
First Name:RAQUEL
Middle Name:MARIA
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 1:142 WATERS EDGE DR
Mailing Address - Street 2:
Mailing Address - City:LIZELLA
Mailing Address - State:GA
Mailing Address - Zip Code:31052-3629
Mailing Address - Country:US
Mailing Address - Phone:478-744-9920
Mailing Address - Fax:
Practice Address - Street 1:5300 MEMORIAL DR STE 121
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30083-3154
Practice Address - Country:US
Practice Address - Phone:404-254-4500
Practice Address - Fax:404-254-4517
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-20
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA032674207QA0401X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000449721SMedicaid
GA000449721SMedicaid