Provider Demographics
NPI:1386623817
Name:WATSON, KEITH A (MD)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:A
Last Name:WATSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 KAHOE LN
Mailing Address - Street 2:
Mailing Address - City:YELLOW SPRINGS
Mailing Address - State:OH
Mailing Address - Zip Code:45387-1243
Mailing Address - Country:US
Mailing Address - Phone:937-767-7311
Mailing Address - Fax:937-767-7107
Practice Address - Street 1:100 KAHOE LN
Practice Address - Street 2:
Practice Address - City:YELLOW SPRINGS
Practice Address - State:OH
Practice Address - Zip Code:45387-1243
Practice Address - Country:US
Practice Address - Phone:937-767-7311
Practice Address - Fax:937-767-7107
Is Sole Proprietor?:No
Enumeration Date:2006-01-12
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-04-3758-W207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0496780Medicaid
OH160038944OtherR/R MEDICARE PIN
OH311144553026OtherCARESOURCE PIN
OHCO2360Medicare UPIN
OHH021330Medicare PIN
OH0514791Medicare PIN