Provider Demographics
NPI:1093052573
Name:WATERS, DEREK
Entity Type:Individual
Prefix:
First Name:DEREK
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 1:10200 N ARMENIA AVE APT 1404
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33612-7349
Mailing Address - Country:US
Mailing Address - Phone:508-375-8085
Mailing Address - Fax:
Practice Address - Street 1:500 FAIRWAY DR STE 102
Practice Address - Street 2:
Practice Address - City:DEERFIELD BEACH
Practice Address - State:FL
Practice Address - Zip Code:33441-1817
Practice Address - Country:US
Practice Address - Phone:877-418-2978
Practice Address - Fax:866-500-2186
Is Sole Proprietor?:No
Enumeration Date:2013-01-03
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator