Provider Demographics
NPI:1083681118
Name:MCWATTERS, JACK W (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:W
Last Name:MCWATTERS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11085 LITTLE PATUXENT PKWY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21044-2983
Mailing Address - Country:US
Mailing Address - Phone:410-997-7979
Mailing Address - Fax:410-997-9231
Practice Address - Street 1:11085 LITTLE PATUXENT PKWY
Practice Address - Street 2:SUITE 101
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044-2983
Practice Address - Country:US
Practice Address - Phone:410-997-7979
Practice Address - Fax:410-997-9231
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2009-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD27237174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD0005OtherCAREFIRST BCBS PPO,SPP,BC
MD04071OtherAMERIGROUP
MD21750OtherJHHC
MD403161000Medicaid
MD0481422OtherAETNA HEALTHCARE HMO
MD2500675OtherUNITED HEALTHCARE
MD225079OtherMAMSI CARDIOLOGY
MD35016302OtherCAREFIRST BCBS MD
MD4105495OtherAETNA HEALTHCARE NON-HMO
MD0481422OtherAETNA HEALTHCARE HMO
MD225079OtherMAMSI CARDIOLOGY
MD930L421EMedicare ID - Type UnspecifiedMEDICARE