Healthcare Provider Details

I. General information

NPI: 1760496178
Provider Name (Legal Business Name): DANIEL JOHN WATTENDORF M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 FISHER ST RM 1A132
KEESLER AFB MS
39534-2159
US

IV. Provider business mailing address

301 FISHER ST RM 1A132
KEESLER AFB MS
39534-2159
US

V. Phone/Fax

Practice location:
  • Phone: 228-377-6393
  • Fax: 228-377-6304
Mailing address:
  • Phone: 228-377-6393
  • Fax: 228-377-6304

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD067656L
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207SC0300X
TaxonomyClinical Cytogenetics Physician
License NumberMD067656L
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License NumberMD067656L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: