1871652586 NPI number — DAVID O WATTS CST SFA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871652586 NPI number — DAVID O WATTS CST SFA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WATTS
Provider First Name:
DAVID
Provider Middle Name:
O
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CST SFA
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:
1871652586
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/03/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 950248
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40295-0248
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-489-5730
Provider Business Mailing Address Fax Number:
502-489-5753

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1023 NEW MOODY LN
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
LA GRANGE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40031-9177
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-222-0598
Provider Business Practice Location Address Fax Number:
502-222-7446
Provider Enumeration Date:
12/08/2006

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: 246ZS0410X , with the licence number:  90544 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 246ZC0007X , with the licence number: SA067 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000000210309 . This is a "ANTHEM" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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