Provider Demographics
NPI:1962485524
Name:FOUNDATION RADIOLOGY GROUP PC
Entity Type:Organization
Organization Name:FOUNDATION RADIOLOGY GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:L
Authorized Official - Last Name:WATTS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-285-6901
Mailing Address - Street 1:3509 FRENCH PARK DR STE E
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73034-7291
Mailing Address - Country:US
Mailing Address - Phone:405-285-6901
Mailing Address - Fax:405-285-6902
Practice Address - Street 1:3509 FRENCH PARK DR STE E
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73034-7291
Practice Address - Country:US
Practice Address - Phone:405-285-6901
Practice Address - Fax:405-285-6902
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-28
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200095260AMedicaid
OK100091420BMedicaid
OKDD2341OtherRR MEDICARE