Provider Demographics
NPI:1487759536
Name:WATSON, CHARLES T (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:T
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:PO BOX 1717
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41105-1717
Mailing Address - Country:US
Mailing Address - Phone:606-324-1188
Mailing Address - Fax:606-325-3843
Practice Address - Street 1:2301 LEXINGTON AVE
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41101-2873
Practice Address - Country:US
Practice Address - Phone:606-324-1188
Practice Address - Fax:606-325-3843
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2010-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY17669207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64176696Medicaid
KY64176696Medicaid
KYP400027320Medicare PIN