Basic Information
| Provider Information | |||||||||
| NPI: | 1669562963 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WATSON | ||||||||
| FirstName: | LASAUNDRA | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 340 PRINTERS PKWY | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809103190 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7196306444 | ||||||||
| FaxNumber: | 7192286609 | ||||||||
| Practice Location | |||||||||
| Address1: | 5636 N UNION BLVD | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809181940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7196325700 | ||||||||
| FaxNumber: | 7192601821 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/15/2006 | ||||||||
| LastUpdateDate: | 05/16/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0300X | 29978 | CO | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 13576780 | 05 | CO | MEDICAID |