Provider Demographics
NPI:1578505467
Name:WATERSON, JOHN ROBERT (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ROBERT
Last Name:WATERSON
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:747 52ND ST
Mailing Address - Street 2:CHILDREN'S HOSPITAL & RESEARCH CENTER AT OAKLAND
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-1809
Mailing Address - Country:US
Mailing Address - Phone:510-428-3550
Mailing Address - Fax:
Practice Address - Street 1:747 52ND ST
Practice Address - Street 2:CHILDREN'S HOSPITAL & RESEARCH CENTER AT OAKLAND
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-1809
Practice Address - Country:US
Practice Address - Phone:510-428-3550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2013-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG85487207SG0201X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207SG0201XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Genetics (M.D.)
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G85487Medicaid
CA00G85487Medicaid