Provider Demographics
NPI:1417915547
Name:WATERS, MICHAEL G (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:G
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 1:142 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24541-2922
Mailing Address - Country:US
Mailing Address - Phone:434-797-2828
Mailing Address - Fax:
Practice Address - Street 1:4944 GREENSBORO RD
Practice Address - Street 2:
Practice Address - City:RIDGEWAY
Practice Address - State:VA
Practice Address - Zip Code:24148-3390
Practice Address - Country:US
Practice Address - Phone:276-956-2233
Practice Address - Fax:276-956-1629
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2018-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101045065207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010251001Medicaid
VAA62171Medicare UPIN
VA00W568D01Medicare ID - Type Unspecified