Provider Demographics
NPI:1790992261
Name:WATTS, KENNETH LEROY (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:LEROY
Last Name:WATTS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:KENNY
Other - Middle Name:LEROY
Other - Last Name:WATTS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2228 E 8TH ST
Mailing Address - Street 2:APT B
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64801-5367
Mailing Address - Country:US
Mailing Address - Phone:580-478-7100
Mailing Address - Fax:
Practice Address - Street 1:3020 SAINT JOHNS BLVD
Practice Address - Street 2:SUITE F
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-1564
Practice Address - Country:US
Practice Address - Phone:417-781-4404
Practice Address - Fax:417-781-5845
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2013-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK25530208600000X
MO2013032884208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200116470AMedicaid
OK200116470AMedicaid