Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207T00000X | Neurosurgeon | ME122047 | FL |
NPI | 1013918085 |
---|---|
Provider Name | Clarence Watridge |
First Address | Jacksonville, FL 32224-1865 |
Second Address | Jacksonville, FL 32224-1865 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/08/2005 |
Last Update Date | 13/12/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
A97704 | (02) |