Provider Demographics
NPI:1124015896
Name:WATERS, HARRIS JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:HARRIS
Middle Name:JOHN
Last Name:WATERS
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 1:450 WELCH ST
Mailing Address - Street 2:
Mailing Address - City:SILVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97381-1934
Mailing Address - Country:US
Mailing Address - Phone:503-873-5310
Mailing Address - Fax:503-873-5315
Practice Address - Street 1:450 WELCH ST
Practice Address - Street 2:
Practice Address - City:SILVERTON
Practice Address - State:OR
Practice Address - Zip Code:97381-1934
Practice Address - Country:US
Practice Address - Phone:503-873-5310
Practice Address - Fax:503-873-5315
Is Sole Proprietor?:No
Enumeration Date:2005-09-28
Last Update Date:2010-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD15831174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR082755Medicaid
OR109896OtherMEDICARE PTIN
ORC96681Medicare UPIN
OR109896Medicare ID - Type Unspecified