Healthcare Provider Details

I. General information

NPI: 1205635620
Provider Name (Legal Business Name): DONTAEVIUS WATTS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: TAE WATTS

II. Dates (important events)

Enumeration Date: 03/10/2025
Last Update Date: 03/22/2026
Certification Date: 03/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 FRUIT ST
BOSTON MA
02114-2621
US

IV. Provider business mailing address

115 BENNETT ST APT 1
GREENVILLE SC
29601-1627
US

V. Phone/Fax

Practice location:
  • Phone: 617-726-2000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: