Provider Demographics
NPI:1659843936
Name:WATSON, CHARLES MICHAEL
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:MICHAEL
Last Name:WATSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:CHARLES
Other - Middle Name:MICHAEL
Other - Last Name:WATSON-DIAZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:193 CHESTNUT AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10305-1740
Mailing Address - Country:US
Mailing Address - Phone:347-220-9325
Mailing Address - Fax:
Practice Address - Street 1:193 CHESTNUT AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10305-1740
Practice Address - Country:US
Practice Address - Phone:347-220-9325
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-26
Last Update Date:2018-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009905-1225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant