Provider Demographics
NPI:1578503926
Name:WATERS, JOSEPH L (MD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:L
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:PO BOX 587
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83303-0587
Mailing Address - Country:US
Mailing Address - Phone:208-814-7400
Mailing Address - Fax:208-814-7491
Practice Address - Street 1:746 N COLLEGE RD
Practice Address - Street 2:SUITE A
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-3486
Practice Address - Country:US
Practice Address - Phone:208-814-7265
Practice Address - Fax:208-814-7284
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2015-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM5829207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDP00189860OtherRR MEDICARE
ID004011100Medicaid
IDE90230Medicare UPIN
ID1124602Medicare PIN