Provider Demographics
NPI:1073230405
Name:FONDREN, WATSON DAVID FLOYD (DC)
Entity Type:Individual
Prefix:DR
First Name:WATSON
Middle Name:DAVID FLOYD
Last Name:FONDREN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:BRENT
Mailing Address - State:AL
Mailing Address - Zip Code:35034-4054
Mailing Address - Country:US
Mailing Address - Phone:205-926-5588
Mailing Address - Fax:
Practice Address - Street 1:122 WALNUT ST
Practice Address - Street 2:
Practice Address - City:BRENT
Practice Address - State:AL
Practice Address - Zip Code:35034-4054
Practice Address - Country:US
Practice Address - Phone:205-926-5588
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-26
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2773111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL2773OtherSTATE OF ALABAMA CHIROPRACTIC LICENSE