Provider Demographics
NPI:1487840633
Name:WATERS, LYNN MICHAEL JR (DO)
Entity Type:Individual
Prefix:
First Name:LYNN
Middle Name:MICHAEL
Last Name:WATERS
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:705 WELLS RD STE 300
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-2982
Mailing Address - Country:US
Mailing Address - Phone:904-282-6331
Mailing Address - Fax:904-619-1080
Practice Address - Street 1:3839 COUNTY ROAD 218
Practice Address - Street 2:
Practice Address - City:MIDDLEBURG
Practice Address - State:FL
Practice Address - Zip Code:32068-5708
Practice Address - Country:US
Practice Address - Phone:904-282-5474
Practice Address - Fax:904-282-5824
Is Sole Proprietor?:No
Enumeration Date:2007-09-21
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLOS10513207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1488LOtherBCBS
FL002290100Medicaid
GA003126257AMedicaid
FL002290100Medicaid