Healthcare Provider Details

I. General information

NPI: 1790992261
Provider Name (Legal Business Name): KENNETH LEROY WATTS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: KENNY LEROY WATTS MD

II. Dates (important events)

Enumeration Date: 05/16/2007
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MERCY WAY STE 440
JOPLIN MO
64804-4524
US

IV. Provider business mailing address

100 MERCY WAY STE 440
JOPLIN MO
64804-4524
US

V. Phone/Fax

Practice location:
  • Phone: 417-781-4404
  • Fax:
Mailing address:
  • Phone: 417-781-4404
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number2013032884
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number25530
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: