Provider Demographics
NPI:1801533765
Name:WATTS, MITCHELL CHARLES (RD, LD)
Entity type:Individual
Prefix:
First Name:MITCHELL
Middle Name:CHARLES
Last Name:WATTS
Suffix:
Gender:M
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3900 CROSBY DR APT 727
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40515-1886
Mailing Address - Country:US
Mailing Address - Phone:859-512-2342
Mailing Address - Fax:
Practice Address - Street 1:3900 CROSBY DR APT 727
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40515-1886
Practice Address - Country:US
Practice Address - Phone:859-512-2342
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-12
Last Update Date:2022-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLD.09188133V00000X
KY265354133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered