Provider Demographics
NPI:1154593127
Name:WATAMURA, SCOTT (MD)
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:
Last Name:WATAMURA
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 1:951 COMMERCE PKWY STE 101
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45804-4040
Mailing Address - Country:US
Mailing Address - Phone:419-998-4575
Mailing Address - Fax:419-998-4586
Practice Address - Street 1:1001 BELLEFONTAINE AVE
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45804
Practice Address - Country:US
Practice Address - Phone:419-228-3335
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-30
Last Update Date:2018-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME96579207L00000X
OH35.094788207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3042282Medicaid
OH000001162857OtherANTHEM BCBS