Provider Demographics
NPI:1164517587
Name:WATTERS, R. BRAD (MD)
Entity Type:Individual
Prefix:DR
First Name:R.
Middle Name:BRAD
Last Name:WATTERS
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 1:1001 LAKESIDE AVE E
Mailing Address - Street 2:#1200
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44114-1158
Mailing Address - Country:US
Mailing Address - Phone:216-479-5541
Mailing Address - Fax:216-479-5554
Practice Address - Street 1:10 SEVERANCE CIR
Practice Address - Street 2:
Practice Address - City:CLEVELAND HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44118-1533
Practice Address - Country:US
Practice Address - Phone:216-621-5600
Practice Address - Fax:216-297-2542
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-047800207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0547617Medicaid
OH0547617Medicaid
WA0888571Medicare ID - Type Unspecified