Healthcare Provider Details

I. General information

NPI: 1336555911
Provider Name (Legal Business Name): LAURA JEAN WATT M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2014
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1285 FRANCISCAN DR
LITCHFIELD IL
62056-1778
US

IV. Provider business mailing address

1285 FRANCISCAN DR
LITCHFIELD IL
62056-1778
US

V. Phone/Fax

Practice location:
  • Phone: 217-324-6127
  • Fax: 217-324-5959
Mailing address:
  • Phone: 217-324-6127
  • Fax: 217-324-5959

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036143454
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: