Provider Demographics
NPI:1154447605
Name:WATTS, VAN BUREN III
Entity Type:Individual
Prefix:
First Name:VAN BUREN
Middle Name:
Last Name:WATTS
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11216 CHERRY HILL RD
Mailing Address - Street 2:T1
Mailing Address - City:BELTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20705-3821
Mailing Address - Country:US
Mailing Address - Phone:301-595-0646
Mailing Address - Fax:
Practice Address - Street 1:7501 GREENWAY CENTER DR
Practice Address - Street 2:STE 800
Practice Address - City:GREENBELT
Practice Address - State:MD
Practice Address - Zip Code:20770-3514
Practice Address - Country:US
Practice Address - Phone:301-220-3009
Practice Address - Fax:301-220-2373
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD20689225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDG700193Medicare ID - Type Unspecified