Provider Demographics
NPI:1427147438
Name:WATTS, SAMUEL M (MD)
Entity type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:M
Last Name:WATTS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 2580
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65801-2580
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:417-829-4316
Practice Address - Street 1:1319 S LANDRUM ST
Practice Address - Street 2:SUITE A
Practice Address - City:MOUNT VERNON
Practice Address - State:MO
Practice Address - Zip Code:65712-1910
Practice Address - Country:US
Practice Address - Phone:417-466-2001
Practice Address - Fax:417-466-2005
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2008-07-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MOR5A74207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO201690013Medicaid
MO015013230Medicare PIN
MO201690013Medicaid
MO478013268Medicare PIN