Provider Demographics
NPI:1407168669
Name:WATTS, BRENDA BANTADOS (MD)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:BANTADOS
Last Name:WATTS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1240 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92021-4994
Mailing Address - Country:US
Mailing Address - Phone:619-515-2300
Mailing Address - Fax:619-269-0674
Practice Address - Street 1:1000 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:NATIONAL CITY
Practice Address - State:CA
Practice Address - Zip Code:91950-3856
Practice Address - Country:US
Practice Address - Phone:619-515-2399
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-04
Last Update Date:2020-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA119649207R00000X
NY272664207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program