Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207QA0401X | Family Doctor - Addiction Medicine | 50616 | CO |
NPI | 1013084821 |
---|---|
Provider Name | Robert William Watrous |
First Address | San Bernardino, CA 92410-3320 |
Second Address | San Bernardino, CA 92410-3320 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/11/2006 |
Last Update Date | 13/04/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
022362 | KAISER COMMERCIAL NUMBER (01) | CO |
63631717 | (05) | CO |