Provider Demographics
NPI:1194733808
Name:HARESCH, JOHN WATTS (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:WATTS
Last Name:HARESCH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JOHN
Other - Middle Name:WILLIAM
Other - Last Name:WATTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2401 E ST NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20225
Mailing Address - Country:US
Mailing Address - Phone:202-663-1718
Mailing Address - Fax:
Practice Address - Street 1:6365 N CROATAN HWY
Practice Address - Street 2:SUITE B
Practice Address - City:KITTY HAWK
Practice Address - State:NC
Practice Address - Zip Code:27949-3800
Practice Address - Country:US
Practice Address - Phone:252-480-6631
Practice Address - Fax:252-480-6630
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200101152207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5906425Medicaid
H93952Medicare UPIN
2067432Medicare PIN