Provider Demographics
NPI:1609194133
Name:WATERS, MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
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 1:1301 TRUMANSBURG RD
Mailing Address - Street 2:SUITE P
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-1397
Mailing Address - Country:US
Mailing Address - Phone:607-277-2365
Mailing Address - Fax:
Practice Address - Street 1:16 BRENTWOOD DR STE A
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-1863
Practice Address - Country:US
Practice Address - Phone:607-277-2365
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-07
Last Update Date:2016-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY284573207XS0106X, 207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery