Provider Demographics
NPI:1134106974
Name:WATERS, JUDITH KUCZEK (MD)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:KUCZEK
Last Name:WATERS
Suffix:
Gender:F
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:PO BOX 30610
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44130-0610
Mailing Address - Country:US
Mailing Address - Phone:440-816-6429
Mailing Address - Fax:440-816-6438
Practice Address - Street 1:18181 PEARL RD
Practice Address - Street 2:B202
Practice Address - City:STRONGSVILLE
Practice Address - State:OH
Practice Address - Zip Code:44136-6949
Practice Address - Country:US
Practice Address - Phone:440-816-4960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-06-7582-W207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH080163899OtherRAILROAD MEDICARE
OH2238199Medicaid
OH86542OtherQUAL CHOICE
OH0007634033OtherAETNA
OH341652755011OtherTRICARE
OH000000077081OtherANTHEM PIN
OH2123544Medicaid
OH0843940002OtherDMERC
OH3416527556P00OtherANTHEM GROUP
OH2123544Medicaid
OH341652755011OtherTRICARE
OHWA0883385Medicare PIN