Healthcare Provider Details

I. General information

NPI: 1750469987
Provider Name (Legal Business Name): TABITHA A WATTS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 02/26/2025
Certification Date: 02/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1449 S MICHIGAN AVE # 1307
CHICAGO IL
60605-2810
US

IV. Provider business mailing address

PO BOX 4645
CHICAGO IL
60680-4645
US

V. Phone/Fax

Practice location:
  • Phone: 888-437-2682
  • Fax: 312-264-0662
Mailing address:
  • Phone: 312-451-5695
  • Fax: 312-264-0662

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number137-320
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01092245A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number036-108494
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number01092245A
License Number StateIN
# 5
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036-108494
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: