Provider Demographics
NPI:1356302715
Name:WATERS, PATRICK TIMOTHY (DO, FAAFP)
Entity Type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:TIMOTHY
Last Name:WATERS
Suffix:
Gender:M
Credentials:DO, FAAFP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1395 NW 167TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33169-5710
Mailing Address - Country:US
Mailing Address - Phone:267-866-7211
Mailing Address - Fax:267-202-7398
Practice Address - Street 1:2101 W LEHIGH AVE STE A
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19132-2664
Practice Address - Country:US
Practice Address - Phone:267-866-7211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-28
Last Update Date:2020-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA0S003179L207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA85987OtherAETNA HMO ONLY
PA0058143000OtherKEYSTONE AND BLUE INDIV #
PA85987OtherAETNA HMO ONLY
PAB40730Medicare UPIN