Provider Demographics
NPI:1427122282
Name:WATSON, WILLIAM BRUCE (MD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:BRUCE
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 1:107 E BURKE AVE
Mailing Address - Street 2:
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21286-1118
Mailing Address - Country:US
Mailing Address - Phone:410-828-8113
Mailing Address - Fax:
Practice Address - Street 1:201 E UNIVERSITY PKWY
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21218-2829
Practice Address - Country:US
Practice Address - Phone:410-554-2107
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD54594207P00000X
DCMD31689207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD75859901OtherBLUE SHIELD
MD75859903OtherBLUE SHIELD
MS0010142Medicaid
MS0010142Medicaid
7611744DMedicare ID - Type Unspecified
MD761L744DMedicare PIN