Provider Demographics
NPI:1326025743
Name:WATT, KEVIN J (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:J
Last Name:WATT
Suffix:
Gender:M
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 1314
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45401-1314
Mailing Address - Country:US
Mailing Address - Phone:937-274-2733
Mailing Address - Fax:937-274-2737
Practice Address - Street 1:6310 N MAIN ST
Practice Address - Street 2:STE A
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45415-3148
Practice Address - Country:US
Practice Address - Phone:937-274-2733
Practice Address - Fax:937-274-2737
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-28
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE22111152W00000X
OH71393207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2111324Medicaid
NE47082635818Medicaid
NE00042OtherBLUE CROSS BLUE SHIELD
NE00042OtherBLUE CROSS BLUE SHIELD
NE47082635818Medicaid