Provider Demographics
NPI:1891228557
Name:WATZA, COURTNEY ELIZABETH
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:ELIZABETH
Last Name:WATZA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:COURTNEY
Other - Middle Name:ELIZABETH
Other - Last Name:CHASE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5471 DR MARTIN LUTHER KING DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63112-4265
Mailing Address - Country:US
Mailing Address - Phone:314-623-9266
Mailing Address - Fax:
Practice Address - Street 1:5471 DR MARTIN LUTHER KING DR
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63112-4265
Practice Address - Country:US
Practice Address - Phone:314-623-9266
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-09
Last Update Date:2022-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301502459208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics