Provider Demographics
NPI:1295817575
Name:WATERS, KEVIN (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:
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 1:4101 N ROXBORO ST
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27704-2121
Mailing Address - Country:US
Mailing Address - Phone:919-684-8111
Mailing Address - Fax:
Practice Address - Street 1:3475 EWIN RD
Practice Address - Street 2:2ND FLOOR - AESTHETICS CENTER
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27705
Practice Address - Country:US
Practice Address - Phone:919-660-6606
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2013-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC99-00714207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891229JMedicaid
NC2279466Medicare ID - Type Unspecified
C98259Medicare UPIN