1174534465 NPI number — MS. SUSAN GAIL WATTS MS. RD. LD. CDE.

Table of content: MS. SUSAN GAIL WATTS MS. RD. LD. CDE. (NPI 1174534465)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174534465 NPI number — MS. SUSAN GAIL WATTS MS. RD. LD. CDE.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WATTS
Provider First Name:
SUSAN
Provider Middle Name:
GAIL
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MS. RD. LD. CDE.
Provider Gender Code:
F

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:
1174534465
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6700 BRADEN CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KERRVILLE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78028-8000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
830-792-8849
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3600 MEMORIAL BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KERRVILLE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78028-5768
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
830-792-2530
Provider Business Practice Location Address Fax Number:
830-792-2582
Provider Enumeration Date:
08/11/2006

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: 133V00000X , with the licence number:  DT03177 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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