Healthcare Provider Details

I. General information

NPI: 1588653489
Provider Name (Legal Business Name): WATAUGA SURGICAL GROUP PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/14/2005
Last Update Date: 04/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

965 STATE FARM RD
BOONE NC
28607-4948
US

IV. Provider business mailing address

965 STATE FARM RD
BOONE NC
28607-4948
US

V. Phone/Fax

Practice location:
  • Phone: 828-264-2340
  • Fax: 828-262-0731
Mailing address:
  • Phone: 828-264-2340
  • Fax: 828-262-0731

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number
License Number State

VIII. Authorized Official

Name: DAGHER S DAGHER
Title or Position: CEO
Credential: MD
Phone: 828-264-2340