Provider Demographics
NPI:1235233867
Name:WATERS, SCOTT ALAN (MD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:ALAN
Last Name:WATERS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18218 STATE ROAD 37
Mailing Address - Street 2:
Mailing Address - City:HARLAN
Mailing Address - State:IN
Mailing Address - Zip Code:46743-9609
Mailing Address - Country:US
Mailing Address - Phone:260-657-5159
Mailing Address - Fax:260-657-5150
Practice Address - Street 1:18218 STATE ROAD 37
Practice Address - Street 2:
Practice Address - City:HARLAN
Practice Address - State:IN
Practice Address - Zip Code:46743-9609
Practice Address - Country:US
Practice Address - Phone:260-657-5159
Practice Address - Fax:260-657-5150
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ININ01052821207Q00000X
OH35083455W207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200298440Medicaid
IN1677841Medicaid
IN36D1049674OtherCLIA