Provider Demographics
NPI:1033222542
Name:WATTERS, MICHELLE THERESA (MD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:THERESA
Last Name:WATTERS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2121 W TAYLOR ST
Mailing Address - Street 2:SPH/EOHS, OCC. MED., MC 684
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-4224
Mailing Address - Country:US
Mailing Address - Phone:312-413-0369
Mailing Address - Fax:
Practice Address - Street 1:2121 W TAYLOR ST
Practice Address - Street 2:SPH/EOHS, OCC. MED., MC 684
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-4224
Practice Address - Country:US
Practice Address - Phone:312-413-0369
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2008-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-1071322083P0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0500XAllopathic & Osteopathic PhysiciansPreventive MedicinePreventive Medicine/Occupational Environmental Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILD13487Medicare UPIN
ILP13569Medicare ID - Type Unspecified