Provider Demographics
NPI:1225491160
Name:WATTS, CANDACE SUMMER (MD)
Entity type:Individual
Prefix:
First Name:CANDACE
Middle Name:SUMMER
Last Name:WATTS
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1209 MOUNTAIN ROAD PL NE STE 5174
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-7845
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:632 BROADWAY PH
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10012-2614
Practice Address - Country:US
Practice Address - Phone:800-731-4254
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-29
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AK151459207Q00000X
WAMD60852613207Q00000X
CODR.0074500207Q00000X
NMMD20221408207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program