Provider Demographics
NPI:1255630604
Name:WATTERS, VICTORIA M (MD)
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:M
Last Name:WATTERS
Suffix:
Gender:F
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 N SHADELAND AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1355 MARINERS DR
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:IN
Practice Address - Zip Code:46582-7145
Practice Address - Country:US
Practice Address - Phone:574-267-6778
Practice Address - Fax:574-267-3134
Is Sole Proprietor?:No
Enumeration Date:2011-03-24
Last Update Date:2020-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-124156207Q00000X
IN01073377A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1841239274OtherPARTNERS PHYSICIAN GROUP TYPE 2 NPI #
OH0107889Medicaid
OH2551671OtherPARTNERS PHYSICIAN GROUP MEDICAID GROUP #
OH9338635OtherPARTNERS PHYSICIAN GROUP MEDICARE GROUP #
OH1841239274OtherPARTNERS PHYSICIAN GROUP TYPE 2 NPI #