1194733808 NPI number — DR. JOHN WATTS HARESCH MD

Table of content: DR. JOHN WATTS HARESCH MD (NPI 1194733808)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194733808 NPI number — DR. JOHN WATTS HARESCH MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HARESCH
Provider First Name:
JOHN
Provider Middle Name:
WATTS
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WATTS
Provider Other First Name:
JOHN
Provider Other Middle Name:
WILLIAM
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1194733808
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/30/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2401 E ST NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WASHINGTON
Provider Business Mailing Address State Name:
DC
Provider Business Mailing Address Postal Code:
20225
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
202-663-1718
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6365 N CROATAN HWY
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
KITTY HAWK
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27949-3800
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
252-480-6631
Provider Business Practice Location Address Fax Number:
252-480-6630
Provider Enumeration Date:
08/04/2006

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: 207Q00000X , with the licence number:  200101152 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 5906425 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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