Provider Demographics
NPI:1871652586
Name:WATTS, DAVID O (CST SFA)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:O
Last Name:WATTS
Suffix:
Gender:M
Credentials:CST SFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 950248
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40295-0248
Mailing Address - Country:US
Mailing Address - Phone:502-489-5730
Mailing Address - Fax:502-489-5753
Practice Address - Street 1:1023 NEW MOODY LN
Practice Address - Street 2:SUITE 102
Practice Address - City:LA GRANGE
Practice Address - State:KY
Practice Address - Zip Code:40031-9177
Practice Address - Country:US
Practice Address - Phone:502-222-0598
Practice Address - Fax:502-222-7446
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY90544246ZS0410X
KYSA067246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
No246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000210309OtherANTHEM