Provider Demographics
NPI:1942470828
Name:WATERFORD FAMILY MEDICINE PC
Entity Type:Organization
Organization Name:WATERFORD FAMILY MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:J
Authorized Official - Last Name:WELLS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:563-355-9990
Mailing Address - Street 1:1820 E 54TH ST
Mailing Address - Street 2:STE B
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807-2797
Mailing Address - Country:US
Mailing Address - Phone:563-355-9990
Mailing Address - Fax:563-355-9999
Practice Address - Street 1:1820 E 54TH ST
Practice Address - Street 2:STE B
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-2797
Practice Address - Country:US
Practice Address - Phone:563-355-9990
Practice Address - Fax:563-355-9999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-06
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1093794968207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA49490OtherBLUE SHIELD
IA7100883Medicaid
I3990Medicare UPIN