Provider Demographics
NPI:1457585481
Name:WATOTO PEDIATRIC & ADOLESCENT SPECIALTY, LLC
Entity Type:Organization
Organization Name:WATOTO PEDIATRIC & ADOLESCENT SPECIALTY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:IRVING
Authorized Official - Middle Name:C
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:571-248-0679
Mailing Address - Street 1:7915 LAKE MANASSAS DRIVE
Mailing Address - Street 2:SUITE 209
Mailing Address - City:GAINESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20155-3260
Mailing Address - Country:US
Mailing Address - Phone:571-248-0679
Mailing Address - Fax:571-261-9549
Practice Address - Street 1:7915 LAKE MANASSAS DRIVE
Practice Address - Street 2:SUITE 209
Practice Address - City:GAINESVILLE
Practice Address - State:VA
Practice Address - Zip Code:20155-3260
Practice Address - Country:US
Practice Address - Phone:571-248-0679
Practice Address - Fax:571-261-9549
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-05
Last Update Date:2009-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty