Healthcare Provider Details

I. General information

NPI: 1699315366
Provider Name (Legal Business Name): WATERTOWN PHYSICIAN PRACTICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2020
Last Update Date: 06/26/2025
Certification Date: 06/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 DODGE ST
WATERTOWN WI
53094-4434
US

IV. Provider business mailing address

680 S 4TH ST
LOUISVILLE KY
40202-2407
US

V. Phone/Fax

Practice location:
  • Phone: 920-262-1460
  • Fax:
Mailing address:
  • Phone: 502-596-6063
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: JOHNETTA TRAYLOR
Title or Position: AO
Credential:
Phone: 502-596-6063