Provider Demographics
NPI:1235159385
Name:WATERS, STEPHANIE RENEE (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:RENEE
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 1:804 BELVEDERE ST
Mailing Address - Street 2:
Mailing Address - City:CARLISLE
Mailing Address - State:PA
Mailing Address - Zip Code:17013-4001
Mailing Address - Country:US
Mailing Address - Phone:717-243-1653
Mailing Address - Fax:717-243-6708
Practice Address - Street 1:804 BELVEDERE ST
Practice Address - Street 2:
Practice Address - City:CARLISLE
Practice Address - State:PA
Practice Address - Zip Code:17013
Practice Address - Country:US
Practice Address - Phone:717-243-1653
Practice Address - Fax:717-243-6708
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2009-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC18655208000000X
PAMD437871208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCG96549Medicare UPIN