Provider Demographics
NPI:1013084821
Name:WATROUS, ROBERT WILLIAM (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:WILLIAM
Last Name:WATROUS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 S G ST
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92410-3320
Mailing Address - Country:US
Mailing Address - Phone:909-382-7100
Mailing Address - Fax:
Practice Address - Street 1:250 S G ST
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92410-3320
Practice Address - Country:US
Practice Address - Phone:909-382-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2024-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG81561207QA0401X
CO50616207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO022362OtherKAISER COMMERCIAL NUMBER
CO63631717Medicaid
CO63631717Medicaid