Provider Demographics
NPI:1174551402
Name:WATSON, LARRY C (MD)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:C
Last Name:WATSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2060 SPACE PARK DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77058-3600
Mailing Address - Country:US
Mailing Address - Phone:281-333-1703
Mailing Address - Fax:281-333-5970
Practice Address - Street 1:2060 SPACE PARK DR
Practice Address - Street 2:SUITE 100
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77058-3600
Practice Address - Country:US
Practice Address - Phone:281-333-1703
Practice Address - Fax:281-333-5970
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-28
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD9711208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8AJ295OtherBCBS
TX034248701Medicaid
TX034248703Medicaid
TX8GD916OtherBCBS
TX034248702Medicaid
TX8ER636OtherBCBS
TX8AJ295OtherBCBS
TX8GD916OtherBCBS
TX369997YMVQMedicare PIN
TX369997ZSWDMedicare PIN