Provider Demographics
NPI:1205863107
Name:WATERS, KEITH H (MD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:H
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:PO BOX 887
Mailing Address - Street 2:
Mailing Address - City:SIMPSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29681
Mailing Address - Country:US
Mailing Address - Phone:864-967-4982
Mailing Address - Fax:864-967-8465
Practice Address - Street 1:103 FAIRVIEW POINTE DRIVE
Practice Address - Street 2:
Practice Address - City:SIMPSONVILLE
Practice Address - State:SC
Practice Address - Zip Code:29681
Practice Address - Country:US
Practice Address - Phone:864-967-4982
Practice Address - Fax:864-967-8465
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC9105207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP0435Medicaid
6557Medicare ID - Type Unspecified
B91925Medicare UPIN