Healthcare Provider Details

I. General information

NPI: 1205132701
Provider Name (Legal Business Name): BRIAN ALLAN WATTS PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2011
Last Update Date: 06/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3121 UNIVERSITY DR E SUITE 100
BRYAN TX
77802-3473
US

IV. Provider business mailing address

3121 UNIVERSITY DR E SUITE 100
BRYAN TX
77802-3473
US

V. Phone/Fax

Practice location:
  • Phone: 979-776-0169
  • Fax: 979-776-1372
Mailing address:
  • Phone: 979-776-0169
  • Fax: 979-776-1372

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberPT4699
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1236349
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: