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General NPI Number Information
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NPI Number | 1376725978
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Entity Type | Organization
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Legal Business Name | EAGLES LANDING DIABETES AND ENDOCRINOLOGY
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Dates
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Enumeration Date | 12/05/2007
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Last Update Date | 06/13/2021
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Provider Practice Location Address
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Address Line | 550 EAGLES LANDING PKWY STE 110
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City | STOCKBRIDGE
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State | GA
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Zip | 30281-9083
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Country | US
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Telephone | 770-389-9494
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Fax | 770-357-2511
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Provider Business Mailing Address
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Address Line | 550 EAGLES LANDING PKWY STE 110
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City | STOCKBRIDGE
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State | GA
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Zip | 30281-9083
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Country | US
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Telephone | 770-389-9494
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Fax | 770-357-2511
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Authorized Official
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Title or Position | OWNER
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Name | DR. RONALD STEVEN WATTS
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Credential | M.D.
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Telephone | 770-389-9494
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 044862
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License Number State | GA
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