Basic Information
| Provider Information | |||||||||
| NPI: | 1528014792 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WATTS | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 283 E 930 S | ||||||||
| Address2: | |||||||||
| City: | OREM | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840585001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012256246 | ||||||||
| FaxNumber: | 8012251525 | ||||||||
| Practice Location | |||||||||
| Address1: | 1034 N 500 W | ||||||||
| Address2: | |||||||||
| City: | PROVO | ||||||||
| State: | UT | ||||||||
| PostalCode: | 846043380 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013737850 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2006 | ||||||||
| LastUpdateDate: | 10/30/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 155859-1205 | UT | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 870284448WA1 | 01 | UT | EMIA | OTHER | 159847 | 01 | UT | DMBA | OTHER | 107006211103 | 01 | UT | IHC | OTHER |