Healthcare Provider Details

I. General information

NPI: 1225000573
Provider Name (Legal Business Name): KYLE ERNEST WATFORD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2006
Last Update Date: 08/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10630 CLEMSON BLVD STE 100
SENECA SC
29678-4545
US

IV. Provider business mailing address

1 INDEPENDENCE POINTE SUITE 212
GREENVILLE SC
29615-4536
US

V. Phone/Fax

Practice location:
  • Phone: 864-482-6000
  • Fax:
Mailing address:
  • Phone: 864-797-6328
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number20275
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License Number20275
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: