1699883454 NPI number — DEREK SCOTT WATSON MD

Table of content: DEREK SCOTT WATSON MD (NPI 1699883454)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699883454 NPI number — DEREK SCOTT WATSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WATSON
Provider First Name:
DEREK
Provider Middle Name:
SCOTT
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1699883454
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/11/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
300 E MCBEE AVE FL 4
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREENVILLE
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29601-2842
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-522-8603
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
727 SE MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 130
Provider Business Practice Location Address City Name:
SIMPSONVILLE
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29681-3247
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-454-6560
Provider Business Practice Location Address Fax Number:
864-454-6565
Provider Enumeration Date:
08/29/2006

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: 2086S0102X , with the licence number:  19376 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X , with the licence number: 19376 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 576007863173 . This is a "BCBS" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: P00392345 . This is a "RR MEDICARE" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: T33951 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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