Provider Demographics
NPI:1275596538
Name:WATERS, MICHAEL G (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:G
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 1:2900 ACME BRICK PLZ
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76109-4123
Mailing Address - Country:US
Mailing Address - Phone:817-871-9069
Mailing Address - Fax:817-871-9067
Practice Address - Street 1:2900 ACME BRICK PLZ
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76109-4123
Practice Address - Country:US
Practice Address - Phone:817-871-9069
Practice Address - Fax:817-871-9067
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-08
Last Update Date:2019-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALDO879208800000X
TXR9886208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009984475Medicaid
AL51525625Medicare ID - Type UnspecifiedMCR PROVIDER NUMBER