Provider Demographics
NPI:1265500938
Name:WATTS, MICHAEL A (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:A
Last Name:WATTS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2963 E COPPER POINT DR
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-9055
Mailing Address - Country:US
Mailing Address - Phone:208-322-1730
Mailing Address - Fax:208-322-1731
Practice Address - Street 1:2963 E COPPER POINT DR
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-9055
Practice Address - Country:US
Practice Address - Phone:208-322-1730
Practice Address - Fax:208-322-1731
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2011-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEEC-06-1097207P00000X
IDM-11231207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDM-11231OtherLICENSE