Healthcare Provider Details

I. General information

NPI: 1124204797
Provider Name (Legal Business Name): MICHAEL D. WATTS, O.D., P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/14/2008
Last Update Date: 05/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1506 BEECH ST
BEDFORD IN
47421-3014
US

IV. Provider business mailing address

1506 BEECH ST
BEDFORD IN
47421-3014
US

V. Phone/Fax

Practice location:
  • Phone: 812-275-7806
  • Fax: 812-275-7852
Mailing address:
  • Phone: 812-275-7806
  • Fax: 812-275-7852

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number18001713A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number StateIN

VIII. Authorized Official

Name: DR. MICHAEL DAVID WATTS
Title or Position: PRESIDENT
Credential: O.D.
Phone: 812-275-7806