Provider Demographics
NPI:1346539319
Name:WATERS, RICHARD CHRISTOPHER
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:CHRISTOPHER
Last Name:WATERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 12TH AVE S
Mailing Address - Street 2:SUITE 901
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98144-2712
Mailing Address - Country:US
Mailing Address - Phone:206-548-3114
Mailing Address - Fax:206-762-6355
Practice Address - Street 1:12721 30TH AVE NE STE 101
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98125-4498
Practice Address - Country:US
Practice Address - Phone:206-417-0326
Practice Address - Fax:206-417-0783
Is Sole Proprietor?:No
Enumeration Date:2011-03-30
Last Update Date:2016-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60479832207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1346539319Medicaid
WA8928937Medicare PIN