Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | 032674 | GA |
N | 207QA0401X | Family Doctor - Addiction Medicine | 032674 | GA |
NPI | 1215936323 |
---|---|
Provider Name | Dr. Raquel Maria Watson |
First Address | Lizella, GA 31052-3629 |
Second Address | Stone Mountain, GA 30083-3154 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 20/07/2005 |
Last Update Date | 17/03/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
000449721S | (05) | GA |