Provider Demographics
NPI:1164420907
Name:DAS-WATTLEY, SHARMILA (DPM)
Entity Type:Individual
Prefix:DR
First Name:SHARMILA
Middle Name:
Last Name:DAS-WATTLEY
Suffix:
Gender:F
Credentials:DPM
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 912
Mailing Address - Street 2:
Mailing Address - City:WILTON
Mailing Address - State:ME
Mailing Address - Zip Code:04294-0912
Mailing Address - Country:US
Mailing Address - Phone:609-922-3653
Mailing Address - Fax:888-519-5127
Practice Address - Street 1:115 MT BLUE CIR
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:ME
Practice Address - Zip Code:04938-6239
Practice Address - Country:US
Practice Address - Phone:207-860-2817
Practice Address - Fax:888-519-5127
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-13
Last Update Date:2013-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPOD1076213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
001867303Medicare PIN