Provider Demographics
NPI:1851477376
Name:WATANABE, GARRETT L (MD)
Entity type:Individual
Prefix:
First Name:GARRETT
Middle Name:L
Last Name:WATANABE
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 1:20380 TOWN CENTER LN
Mailing Address - Street 2:SUITE 215
Mailing Address - City:CUPERTINO
Mailing Address - State:CA
Mailing Address - Zip Code:95014-3210
Mailing Address - Country:US
Mailing Address - Phone:408-996-7950
Mailing Address - Fax:408-996-7997
Practice Address - Street 1:20380 TOWN CENTER LN
Practice Address - Street 2:SUITE 215
Practice Address - City:CUPERTINO
Practice Address - State:CA
Practice Address - Zip Code:95014-3210
Practice Address - Country:US
Practice Address - Phone:408-996-7950
Practice Address - Fax:408-996-7997
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2012-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA744452084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A744450Medicaid
H54604Medicare UPIN
00A744451Medicare ID - Type Unspecified