1255630604 NPI number — VICTORIA M WATTERS M.D.

Table of content: VICTORIA M WATTERS M.D. (NPI 1255630604)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255630604 NPI number — VICTORIA M WATTERS M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WATTERS
Provider First Name:
VICTORIA
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1255630604
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/15/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
250 N SHADELAND AVE STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46219-4959
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1355 MARINERS DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WARSAW
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46582-7145
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-267-6778
Provider Business Practice Location Address Fax Number:
574-267-3134
Provider Enumeration Date:
03/24/2011

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:  01073377A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207Q00000X , with the licence number: 35-124156 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 2551671 . This is a "PARTNERS PHYSICIAN GROUP MEDICAID GROUP #" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 1841239274 . This is a "PARTNERS PHYSICIAN GROUP TYPE 2 NPI #" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 9338635 . This is a "PARTNERS PHYSICIAN GROUP MEDICARE GROUP #" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 0107889 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".