Provider Demographics
NPI:1508816596
Name:WATTERS, THOMAS ALAN (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:ALAN
Last Name:WATTERS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:101 S SAN MATEO DR
Mailing Address - Street 2:SUITE 303
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94401-3819
Mailing Address - Country:US
Mailing Address - Phone:650-218-5758
Mailing Address - Fax:650-375-8398
Practice Address - Street 1:101 S SAN MATEO DR
Practice Address - Street 2:SUITE 303
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94401-3819
Practice Address - Country:US
Practice Address - Phone:650-218-5758
Practice Address - Fax:650-375-8398
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2009-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG50566207UN0901X
HIMD13617207UN0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE91338Medicare UPIN
CA00G505660Medicare PIN
CAZZZ23000ZMedicare ID - Type Unspecified