Provider Demographics
NPI:1427001171
Name:WATTS, CHARLES REGINALD (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:REGINALD
Last Name:WATTS
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 1:3931 LOUISIANA AVE S
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55426-5000
Mailing Address - Country:US
Mailing Address - Phone:952-993-3230
Mailing Address - Fax:952-933-1748
Practice Address - Street 1:3931 LOUISIANA AVE S
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55426-5000
Practice Address - Country:US
Practice Address - Phone:952-993-3230
Practice Address - Fax:952-993-1748
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI61864207T00000X
MN454962086S0102X, 207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN45496OtherMINNESOTA LICENSE
MN607431600Medicaid