Provider Demographics
NPI:1841223096
Name:WAT, JOHN M (DO)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:M
Last Name:WAT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7785 N STATE ST FL 3
Mailing Address - Street 2:
Mailing Address - City:LOWVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13367-1297
Mailing Address - Country:US
Mailing Address - Phone:315-376-5287
Mailing Address - Fax:315-376-3228
Practice Address - Street 1:7785 N STATE ST FL 3
Practice Address - Street 2:
Practice Address - City:LOWVILLE
Practice Address - State:NY
Practice Address - Zip Code:13367-1229
Practice Address - Country:US
Practice Address - Phone:315-376-5287
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY230325207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02642799Medicaid
NY0466P2Medicare ID - Type Unspecified
NYI01866Medicare UPIN