Provider Demographics
NPI:1528146651
Name:WATSON, ALICE C (MD)
Entity type:Individual
Prefix:
First Name:ALICE
Middle Name:C
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 1:44000 W 12 MILE RD STE 103
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48377-2646
Mailing Address - Country:US
Mailing Address - Phone:248-946-4787
Mailing Address - Fax:248-308-2450
Practice Address - Street 1:44000 W 12 MILE RD STE 103
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48377
Practice Address - Country:US
Practice Address - Phone:248-946-4787
Practice Address - Fax:248-716-5956
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301072406207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
0932592OtherBCBS PIN
AW072406OtherCOMMERCIAL-COMMERCIAL NUMBER
0932592OtherBCBS PIN
AW072406OtherCHAMPUS-CHAMPUS
700H262200OtherBLUE CROSS-BLUE CROSS
AW072406OtherCHAMPUS-CHAMPUS