Provider Demographics
NPI:1245209741
Name:WATERS, SCOTT C (DO)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:C
Last Name:WATERS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 W UTOPIA RD STE 100
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85027-4172
Mailing Address - Country:US
Mailing Address - Phone:623-683-4462
Mailing Address - Fax:623-683-4963
Practice Address - Street 1:4712 E DYNAMITE BLVD
Practice Address - Street 2:
Practice Address - City:CAVE CREEK
Practice Address - State:AZ
Practice Address - Zip Code:85331-6243
Practice Address - Country:US
Practice Address - Phone:480-342-8711
Practice Address - Fax:480-342-7077
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2022-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN48083207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN080020962Medicare PIN
H11048Medicare UPIN