1922052075 NPI number — DR. BRUCE A WATT MD

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922052075 NPI number — DR. BRUCE A WATT MD

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

WATT

Provider First Name:

BRUCE

Provider Middle Name:

A

Provider Name Prefix Text:

DR.

Provider Name Suffix Text:

Provider Credential Text:

MD

Provider Gender Code:

M

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:

1922052075

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

08/18/2021

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

PO BOX 5009

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

SIOUX FALLS

Provider Business Mailing Address State Name:

SD

Provider Business Mailing Address Postal Code:

57117-5009

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

605-977-5000

Provider Business Mailing Address Fax Number:

605-977-5377

Provider First Line Business Practice Location Address:

4520 W 69TH ST

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

SIOUX FALLS

Provider Business Practice Location Address State Name:

SD

Provider Business Practice Location Address Postal Code:

57108-8148

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

605-977-5000

Provider Business Practice Location Address Fax Number:

605-977-5377

Provider Enumeration Date:

05/22/2006

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 207RI0011X , with the licence number:  1655 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 207RC0000X , with the licence number: 1655 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 6000872 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
• Identifier: 4T612WA . This is a "MN BCBS - PLAN 91057NO" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: 415088100 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
• Identifier: 0933036 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
• Identifier: 1655 . This is a "DAKOTACARE" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
• Identifier: 24694 . This is a "HEALTH PARTNERS" identifier . This identifiers is of the category "OTHER".
• Identifier: 165035 . This is a "UCARE" identifier . This identifiers is of the category "OTHER".
• Identifier: 931451029050 . This is a "PREFERRED ONE" identifier . This identifiers is of the category "OTHER".
• Identifier: 0003371 . This is a "SD BCBS" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
• Identifier: 25-00495 . This is a "MEDICA SELECTCARE" identifier . This identifiers is of the category "OTHER".
• Identifier: 53997 . This is a "IA BCBS" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
• Identifier: 539ROWA . This is a "MN BCBS - PLAN 538R2NO" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".