1659641975 NPI number — BRIAN M WATTERS D.C.

Table of content: BRIAN M WATTERS D.C. (NPI 1659641975)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659641975 NPI number — BRIAN M WATTERS D.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WATTERS
Provider First Name:
BRIAN
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.C.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1659641975
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/08/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11691 FALL CREEK RD
Provider Second Line Business Mailing Address:
STE 110
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46256-9448
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-688-1711
Provider Business Mailing Address Fax Number:
317-288-4041

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11691 FALL CREEK RD
Provider Second Line Business Practice Location Address:
STE 110
Provider Business Practice Location Address City Name:
INDIANAPOLIS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46256-9448
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-688-1711
Provider Business Practice Location Address Fax Number:
317-288-4041
Provider Enumeration Date:
01/03/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  08002617A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)