1073554150 NPI number — MR. WALLACE CARLISLE WATSON JR. PA

Table of content: MR. WALLACE CARLISLE WATSON JR. PA (NPI 1073554150)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073554150 NPI number — MR. WALLACE CARLISLE WATSON JR. PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WATSON
Provider First Name:
WALLACE
Provider Middle Name:
CARLISLE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
PA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073554150
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/28/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2211 W STATE ST
Provider Second Line Business Mailing Address:
SUITE 121
Provider Business Mailing Address City Name:
OLEAN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14760-1951
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
716-372-2708
Provider Business Mailing Address Fax Number:
716-372-8682

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
21 E MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CUBA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14727-1205
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
585-968-4357
Provider Business Practice Location Address Fax Number:
585-968-4356
Provider Enumeration Date:
06/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X , with the licence number:  0012551 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: 001255 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0490352 . This is a "IHA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 00010257702 . This is a "UNIVERA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 407113852 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000508499002 . This is a "BCWNY" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 2598491 . This is a "GHI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 01531593 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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