Provider Demographics
NPI:1124204797
Name:MICHAEL D. WATTS, O.D., P.C.
Entity Type:Organization
Organization Name:MICHAEL D. WATTS, O.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:WATTS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:812-275-7806
Mailing Address - Street 1:1506 BEECH ST
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:IN
Mailing Address - Zip Code:47421-3014
Mailing Address - Country:US
Mailing Address - Phone:812-275-7806
Mailing Address - Fax:812-275-7852
Practice Address - Street 1:1506 BEECH ST
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:IN
Practice Address - Zip Code:47421-3014
Practice Address - Country:US
Practice Address - Phone:812-275-7806
Practice Address - Fax:812-275-7852
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-14
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001713A152W00000X
IN332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200887880AMedicaid
IN0171170001Medicare NSC
IN494490Medicare PIN