MEDICARE: TERESSA MCKOY WATTS MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	9600299	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1003C	OTHER	NC	NCBCBS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1932129053
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TERESSA MCKOY WATTS MD

Provider Business Mailing Address
First Line	:	PO BOX 601067
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28260-1067
Country	:	US
Telephone Number	:	704-801-3050
Fax Number	:	704-801-3026

Provider Business Practice Location Address
First Line	:	9908 COULOAK DR
Second Line	:	SUITE 202
City	:	CHARLOTTE
State	:	NC
Zip	:	28216-8678
Country	:	US
Telephone Number	:	704-801-3050
Fax Number	:	704-801-3026

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/20/2006
Last Update Date	:	10/28/2014

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