Provider Demographics
NPI:1629077854
Name:WATTENMAKER, IAN MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:MICHAEL
Last Name:WATTENMAKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:224D CORNWALL ST NW STE 403
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20176-2704
Mailing Address - Country:US
Mailing Address - Phone:703-737-6010
Mailing Address - Fax:703-443-8643
Practice Address - Street 1:19450 DEERFIELD AVENUE, SUITE 200
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20176-6821
Practice Address - Country:US
Practice Address - Phone:703-777-1553
Practice Address - Fax:703-777-5524
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101049672207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA30015845120002Medicaid
VA1629077854Medicaid