Provider Demographics
NPI:1043200579
Name:WATERS, BRENDAN L (DO)
Entity Type:Individual
Prefix:
First Name:BRENDAN
Middle Name:L
Last Name:WATERS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22314-3868
Mailing Address - Country:US
Mailing Address - Phone:215-432-3072
Mailing Address - Fax:
Practice Address - Street 1:2300 OPITZ BLVD
Practice Address - Street 2:DEPT OF RADIOLOGY
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191
Practice Address - Country:US
Practice Address - Phone:703-607-1561
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2013-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01022017252085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
007676P33Medicare ID - Type Unspecified
I31597Medicare UPIN