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General NPI Number Information
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NPI Number | 1528558749
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Entity Type | Organization
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Legal Business Name | WATERTOWN PHYSICIAN PRACTICES LLC
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Dates
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Enumeration Date | 05/14/2018
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Last Update Date | 06/26/2025
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Provider Practice Location Address
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Address Line | 123 HOSPITAL DR STE 2005
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City | WATERTOWN
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State | WI
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Zip | 53098
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Country | US
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Telephone | 920-206-3155
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Fax | 920-206-3158
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Provider Business Mailing Address
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Address Line | 680 S 4TH ST
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City | LOUISVILLE
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State | KY
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Zip | 40202-2407
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Country | US
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Telephone | 502-596-6063
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Fax |
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Authorized Official
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Title or Position | AO
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Name | JOHNETTA TRAYLOR
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Credential |
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Telephone | 502-596-6063
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332H00000X
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Taxonomy Name | Eyewear Supplier
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number |
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License Number State |
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