| Doctor Name: | MR. WALLACE CARLISLE WATSON |
| NPI Number: | 1073554150 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | PA |
| License Number: | 0012551 |
| Business Practice Address: | 21 E Main St Cuba, NY - 147271205 |
| Business Phone Number: | 5859684357 |
| Business Fax Number: | 5859684356 |
| Mailing Address: | 2211 W State St, Suite 121 OLEAN |
| State: | NY |
| Postal Code: | 147601951 |
| Phone Number: | 7163722708 |
| Fax Number: | 7163728682 |
| NPI Enumeration Date: | 06/09/2006 |
| NPI Last Update Date: | 05/28/2013 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 208D00000X |
| License Number: | 0012551 |
| Healthcare Provider Taxonomy: (Secondary) | N |
| State: | NY |
| Taxonomy Type: | Allopathic & Osteopathic Physicians |
| Taxonomy Classification: | General Practice |
| Taxonomy Specialization: | |
| Taxonomy Definition: | |