Provider Demographics
NPI:1801811203
Name:WATT, JONATHAN VINCENT (MD)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:VINCENT
Last Name:WATT
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 1:3619 NE 174TH ST
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98686-1864
Mailing Address - Country:US
Mailing Address - Phone:360-574-4163
Mailing Address - Fax:
Practice Address - Street 1:3619 NE 174TH ST
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98686-1864
Practice Address - Country:US
Practice Address - Phone:360-574-4163
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00023791207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8415598Medicaid
WA8415598Medicaid
A08105Medicare UPIN