Provider Demographics
NPI:1528113313
Name:WATSON, URSULA ALICE (MD)
Entity type:Individual
Prefix:DR
First Name:URSULA
Middle Name:ALICE
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 1:625 KINGS GRANT WALK
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30075-5528
Mailing Address - Country:US
Mailing Address - Phone:770-518-1354
Mailing Address - Fax:770-557-0953
Practice Address - Street 1:6920 JIMMY CARTER BLVD STE 100
Practice Address - Street 2:
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30071-1246
Practice Address - Country:US
Practice Address - Phone:770-449-0990
Practice Address - Fax:770-448-8818
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2010-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA 026675207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA581762046OtherGA CLINIC TAX ID
GA000425565GOtherGA URGENT CARE MCAID ID
GA511I930104OtherGA URGENT CARE MCARE PIN
GA581762046OtherGA CLINIC TAX ID
GAGRP 2768Medicare ID - Type UnspecifiedGA CLINIC GRP NUMBER