Provider Demographics
NPI:1073539334
Name:WATERS, TUTASI K (MD)
Entity Type:Individual
Prefix:
First Name:TUTASI
Middle Name:K
Last Name:WATERS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:680 CENTRE ST
Mailing Address - Street 2:CREDENTIALING DEPARTMENT
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02302-3308
Mailing Address - Country:US
Mailing Address - Phone:508-941-7009
Mailing Address - Fax:508-583-2515
Practice Address - Street 1:2 WASHINGTON ST STE 210
Practice Address - Street 2:
Practice Address - City:NORTH EASTON
Practice Address - State:MA
Practice Address - Zip Code:02356-1011
Practice Address - Country:US
Practice Address - Phone:508-894-8750
Practice Address - Fax:508-894-8752
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2015-05-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA205083207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0110540Medicaid
MAH27146Medicare UPIN
MAA31573Medicare PIN