Provider Demographics
NPI:1003872201
Name:WATTERS, RUSSELL BRANDON III (MD)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:BRANDON
Last Name:WATTERS
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 325
Mailing Address - Street 2:
Mailing Address - City:ETOWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37331-0325
Mailing Address - Country:US
Mailing Address - Phone:423-263-2444
Mailing Address - Fax:423-263-1553
Practice Address - Street 1:301 GRADY RD
Practice Address - Street 2:
Practice Address - City:ETOWAH
Practice Address - State:TN
Practice Address - Zip Code:37331-1903
Practice Address - Country:US
Practice Address - Phone:423-263-2444
Practice Address - Fax:423-263-1553
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN023529207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN2008341OtherBCBS
TN3069752Medicaid
E44337Medicare UPIN
TN3069753Medicare PIN