Healthcare Provider Details

I. General information

NPI: 1699178293
Provider Name (Legal Business Name): DEVARRA WATSON CASAL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2014
Last Update Date: 09/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 POWERS CV
ATLANTA GA
30327-3405
US

IV. Provider business mailing address

PO BOX 421158
ATLANTA GA
30342-8158
US

V. Phone/Fax

Practice location:
  • Phone: 404-565-0247
  • Fax:
Mailing address:
  • Phone: 404-565-0247
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number040341
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: