Healthcare Provider Details

I. General information

NPI: 1598127615
Provider Name (Legal Business Name): MITCHELL WATTLES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2016
Last Update Date: 09/20/2022
Certification Date: 09/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

675 OLD BALLAS RD STE 100
SAINT LOUIS MO
63141-7083
US

IV. Provider business mailing address

675 OLD BALLAS RD STE 100
SAINT LOUIS MO
63141-7083
US

V. Phone/Fax

Practice location:
  • Phone: 314-733-9009
  • Fax:
Mailing address:
  • Phone: 314-733-9009
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number28415
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberR4193
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number2022036718
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: