Provider Demographics
NPI:1760496178
Name:WATTENDORF, DANIEL JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:JOHN
Last Name:WATTENDORF
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 1:301 FISHER ST
Mailing Address - Street 2:RM 1A132
Mailing Address - City:KEESLER AFB
Mailing Address - State:MS
Mailing Address - Zip Code:39534-2159
Mailing Address - Country:US
Mailing Address - Phone:228-377-6393
Mailing Address - Fax:228-377-6304
Practice Address - Street 1:301 FISHER ST
Practice Address - Street 2:RM 1A132
Practice Address - City:KEESLER AFB
Practice Address - State:MS
Practice Address - Zip Code:39534-2159
Practice Address - Country:US
Practice Address - Phone:228-377-6393
Practice Address - Fax:228-377-6304
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD067656L207Q00000X, 207SC0300X, 207SG0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Not Answered207SC0300XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Cytogenetics
Not Answered207SG0201XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Genetics (M.D.)