Provider Demographics
NPI:1114009578
Name:WATTS, SHANNON L (MD)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:L
Last Name:WATTS
Suffix:
Gender:F
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 733784
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-3784
Mailing Address - Country:US
Mailing Address - Phone:682-885-1855
Mailing Address - Fax:682-885-1396
Practice Address - Street 1:3906 E US HIGHWAY 377 STE 110
Practice Address - Street 2:
Practice Address - City:GRANBURY
Practice Address - State:TX
Practice Address - Zip Code:76049-7609
Practice Address - Country:US
Practice Address - Phone:817-279-1390
Practice Address - Fax:817-573-5150
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ6048208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX5618256OtherAETNA PIN
TX00U87ZOtherBCBSTX GRP PIN
TX1399858OtherUHC PIN
TX140442860Medicaid
TX3447654OtherCIGNA PIN
TX87013GOtherBCBSTX IND PIN
TXWATSG13439OtherCCHIP PIN
TX126490101OtherFIRSTCARE PIN
TX137072802Medicaid
1750369203OtherGRP NPI NUMBER
TX965043OtherFIRSTHEALTH PIN
TX117559805Medicaid
TX87013GOtherBCBSTX IND PIN
TX5618256OtherAETNA PIN
TX3447654OtherCIGNA PIN