Provider Demographics
NPI:1225000573
Name:WATFORD, KYLE ERNEST (MD)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:ERNEST
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 1:1 INDEPENDENCE POINTE
Mailing Address - Street 2:SUITE 212
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4536
Mailing Address - Country:US
Mailing Address - Phone:864-797-6328
Mailing Address - Fax:
Practice Address - Street 1:10630 CLEMSON BLVD STE 100
Practice Address - Street 2:
Practice Address - City:SENECA
Practice Address - State:SC
Practice Address - Zip Code:29678-4545
Practice Address - Country:US
Practice Address - Phone:864-482-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2017-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC20275207X00000X, 207XX0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0801XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Trauma
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC055OtherBCBS
SC206186OtherMEDCOST
SC7574373OtherAETNA
SC202756Medicaid
NC5909037OtherNC MEDICAID
SC8000830OtherCIGNA
SC20072627OtherSELECT HEALTH
SCH640278552OtherMEDICARE PTAN
SCH640278552Medicare UPIN
SC202756Medicaid