Provider Demographics
NPI:1881906022
Name:WATSON, SAMUEL JACOB (MD)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:JACOB
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 1:496 SOUTHLAND DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-1827
Mailing Address - Country:US
Mailing Address - Phone:859-288-2392
Mailing Address - Fax:859-721-3918
Practice Address - Street 1:1640 BRYAN STATION RD STE 1
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40505-2144
Practice Address - Country:US
Practice Address - Phone:859-288-2425
Practice Address - Fax:859-721-3918
Is Sole Proprietor?:No
Enumeration Date:2010-07-03
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY46559208000000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY108752OtherCERTIFICATION
KY7100253290Medicaid
KY46559OtherKENTUCKY BOARD OF MEDICAL LICENSURE