Healthcare Provider Details

I. General information

NPI: 1306089552
Provider Name (Legal Business Name): CHARLES WILLIAM WATTS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/16/2009
Last Update Date: 08/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 FOOTHILL DR 111-BH
SALT LAKE CITY UT
84148-0001
US

IV. Provider business mailing address

1352 FILMORE ST
SALT LAKE CITY UT
84105-2706
US

V. Phone/Fax

Practice location:
  • Phone: 801-582-1565
  • Fax:
Mailing address:
  • Phone: 801-859-6895
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number7771544-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: