Provider Demographics
NPI:1154399186
Name:WATTS, MARY LYNN (MD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:LYNN
Last Name:WATTS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4260 VAN DYKE RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:ALMONT
Mailing Address - State:MI
Mailing Address - Zip Code:48003-8546
Mailing Address - Country:US
Mailing Address - Phone:810-798-3994
Mailing Address - Fax:586-798-8212
Practice Address - Street 1:4260 VAN DYKE RD
Practice Address - Street 2:SUITE 101
Practice Address - City:ALMONT
Practice Address - State:MI
Practice Address - Zip Code:48003-8546
Practice Address - Country:US
Practice Address - Phone:810-798-3994
Practice Address - Fax:586-798-8212
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2023-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301054742207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4373843Medicaid
MI700E012740OtherBCBS GROUP NUMBER
MI700E012740OtherBCBS GROUP NUMBER
MI4373843Medicaid
MIN40170028Medicare PIN