Basic Information
| Provider Information | |||||||||
| NPI: | 1699919761 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WATTERS | ||||||||
| FirstName: | RAYMOND | ||||||||
| MiddleName: | WENDELL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD,MPH | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1120 | ||||||||
| Address2: | |||||||||
| City: | OWINGSVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403601120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6066746386 | ||||||||
| FaxNumber: | 6066743096 | ||||||||
| Practice Location | |||||||||
| Address1: | 632 SLATE AVE | ||||||||
| Address2: | |||||||||
| City: | OWINGSVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403602206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6066746386 | ||||||||
| FaxNumber: | 6066743096 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2009 | ||||||||
| LastUpdateDate: | 12/17/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 22766 | KY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 22766 | 01 | KY | KENTUCKY BOARD OF MEDICAL LICENSURE | OTHER |