Provider Demographics
NPI:1477512762
Name:WATT, TIM J (MD)
Entity Type:Individual
Prefix:
First Name:TIM
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 1:4141 5TH ST
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-6021
Mailing Address - Country:US
Mailing Address - Phone:605-341-2424
Mailing Address - Fax:605-341-4547
Practice Address - Street 1:4141 5TH ST
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-6021
Practice Address - Country:US
Practice Address - Phone:605-341-2424
Practice Address - Fax:605-341-4547
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2020-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD5120207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6100850Medicaid
WY118029100Medicaid
SD0040744OtherWELLMARK BCBS PROVIDER #
NE22176OtherBCBS PROVIDER NUMBER
NE22176OtherBCBS PROVIDER NUMBER
SDS40744Medicare PIN
NE276180Medicare PIN