Basic Information
| Provider Information | |||||||||
| NPI: | 1578854469 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WATTS | ||||||||
| FirstName: | TIFFANY | ||||||||
| MiddleName: | DAVIS | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DAVIS | ||||||||
| OtherFirstName: | TIFFANY | ||||||||
| OtherMiddleName: | MARIE | ||||||||
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| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 161 FULTON WAY SE | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303122915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2108870995 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1405 CLIFTON RD NE | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303221060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047857141 | ||||||||
| FaxNumber: | 4047857989 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2011 | ||||||||
| LastUpdateDate: | 08/22/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | IL | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208000000X | 072722 | GA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.