Provider Demographics
NPI:1457651846
Name:WATTERS, JACOB WILLIAM (DO)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:WILLIAM
Last Name:WATTERS
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 1:7975 LAKE UNDERHILL RD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32822
Mailing Address - Country:US
Mailing Address - Phone:407-303-8683
Mailing Address - Fax:
Practice Address - Street 1:7675 LAKE UNDERHILL RD
Practice Address - Street 2:SUITE 210
Practice Address - City:ORLANDO
Practice Address - State:TN
Practice Address - Zip Code:32822
Practice Address - Country:US
Practice Address - Phone:407-303-8683
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-01
Last Update Date:2010-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS11073207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine