Healthcare Provider Details

I. General information

NPI: 1396779161
Provider Name (Legal Business Name): JOHN OTIS WAITS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 05/06/2020
Certification Date: 05/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 MCFARLAND BLVD
NORTHPORT AL
35476-3270
US

IV. Provider business mailing address

405 BELCHER ST
CENTREVILLE AL
35042-2946
US

V. Phone/Fax

Practice location:
  • Phone: 205-926-2992
  • Fax: 205-316-7675
Mailing address:
  • Phone: 205-926-2992
  • Fax: 205-316-7675

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number9904
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number9904
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: