Provider Demographics
NPI:1578588976
Name:WATTERSON, WILLIAM (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:
Last Name:WATTERSON
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 1:2410 PAGEHURST DR
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23113-6411
Mailing Address - Country:US
Mailing Address - Phone:804-897-6140
Mailing Address - Fax:804-897-6141
Practice Address - Street 1:2410 PAGEHURST DRIVE
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23113
Practice Address - Country:US
Practice Address - Phone:804-897-6140
Practice Address - Fax:804-897-6141
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2011-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101052275207P00000X
VA101052275207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006736319Medicaid
VA333920OtherBLUE SHIELD
VA333922OtherBLUE SHIELD
VA141554OtherBLUE SHIELD
VA1578588976Medicaid
VAVV0540AMedicare PIN
VA141554OtherBLUE SHIELD
VA1578588976Medicaid
VA930001244Medicare PIN
VA003704V20Medicare PIN