Provider Demographics
NPI:1104884998
Name:WATFORD, DOUGLAS ELRY (MD)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:ELRY
Last Name:WATFORD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5281
Mailing Address - Street 2:
Mailing Address - City:KINSTON
Mailing Address - State:NC
Mailing Address - Zip Code:28503
Mailing Address - Country:US
Mailing Address - Phone:252-527-8906
Mailing Address - Fax:252-527-9816
Practice Address - Street 1:400 GLENWOOD AVE
Practice Address - Street 2:STE 3
Practice Address - City:KINSTON
Practice Address - State:NC
Practice Address - Zip Code:28501
Practice Address - Country:US
Practice Address - Phone:252-527-8906
Practice Address - Fax:252-527-9816
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC35546207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8985984Medicaid
NC8985984Medicaid
2169255FMedicare ID - Type Unspecified