Provider Demographics
NPI:1043536261
Name:WATERS, JEREMY
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:WATERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 449
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:OH
Mailing Address - Zip Code:45750-0449
Mailing Address - Country:US
Mailing Address - Phone:740-374-4500
Mailing Address - Fax:740-374-5887
Practice Address - Street 1:151 ANDERSON LN
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:OH
Practice Address - Zip Code:45786-5312
Practice Address - Country:US
Practice Address - Phone:740-984-2332
Practice Address - Fax:740-984-4435
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-13
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34010331208M00000X, 207R00000X, 208M00000X
WV2565207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0072159Medicaid
WV3810024361Medicaid
OH0072159Medicaid
OHH131861Medicare PIN
OH0072159Medicaid
OHH131860Medicare PIN