Provider Demographics
NPI:1871596726
Name:WATSON, JOHN WARD (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:WARD
Last Name:WATSON
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:PO BOX 3988
Mailing Address - Street 2:1239 E. MAIN STREET
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62902
Mailing Address - Country:US
Mailing Address - Phone:618-457-5200
Mailing Address - Fax:618-351-4821
Practice Address - Street 1:305 W JACKSON ST STE 206
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-1474
Practice Address - Country:US
Practice Address - Phone:618-457-3006
Practice Address - Fax:618-457-3007
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2025-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD071749L208G00000X
IL036116328208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0361167328Medicaid
PA045229Medicare ID - Type Unspecified
PAG91787Medicare UPIN
IL0361167328Medicaid