Basic Information
| Provider Information | |||||||||
| NPI: | 1255630604 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WATTERS | ||||||||
| FirstName: | VICTORIA | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 250 N SHADELAND AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462194959 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1355 MARINERS DR | ||||||||
| Address2: | |||||||||
| City: | WARSAW | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465827145 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742676778 | ||||||||
| FaxNumber: | 5742673134 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2011 | ||||||||
| LastUpdateDate: | 06/15/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 35-124156 | OH | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 01073377A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1841239274 | 01 | OH | PARTNERS PHYSICIAN GROUP TYPE 2 NPI # | OTHER | 0107889 | 05 | OH | MEDICAID | 2551671 | 01 | OH | PARTNERS PHYSICIAN GROUP MEDICAID GROUP # | OTHER | 9338635 | 01 | OH | PARTNERS PHYSICIAN GROUP MEDICARE GROUP # | OTHER |