Provider Demographics
NPI:1558353219
Name:WATTLEWORTH, ROBERTA ANN (DO)
Entity Type:Individual
Prefix:
First Name:ROBERTA
Middle Name:ANN
Last Name:WATTLEWORTH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50312-4104
Mailing Address - Country:US
Mailing Address - Phone:515-271-1710
Mailing Address - Fax:515-271-1575
Practice Address - Street 1:3200 GRAND AVE
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50312-4104
Practice Address - Country:US
Practice Address - Phone:515-271-1710
Practice Address - Fax:515-271-1575
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2010-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA13248207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA080147596OtherRR MEDICARE
IA1250795Medicaid
IA1250795Medicaid
IA04562Medicare PIN