Healthcare Provider Details

I. General information

NPI: 1528014792
Provider Name (Legal Business Name): GARY M WATTS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 10/30/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1034 N 500 W
PROVO UT
84604-3380
US

IV. Provider business mailing address

283 E 930 S
OREM UT
84058-5001
US

V. Phone/Fax

Practice location:
  • Phone: 801-373-7850
  • Fax:
Mailing address:
  • Phone: 801-225-6246
  • Fax: 801-225-1525

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number155859-1205
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier870284448WA1
Identifier TypeOTHER
Identifier StateUT
Identifier IssuerEMIA
# 2
Identifier159847
Identifier TypeOTHER
Identifier StateUT
Identifier IssuerDMBA
# 3
Identifier107006211103
Identifier TypeOTHER
Identifier StateUT
Identifier IssuerIHC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: