Provider Demographics
NPI:1629005772
Name:WATERS, SUSAN E (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:E
Last Name:WATERS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1125 SIR FRANCIS DRAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:KENTFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94904-1418
Mailing Address - Country:US
Mailing Address - Phone:415-485-3524
Mailing Address - Fax:415-485-3507
Practice Address - Street 1:1125 SIR FRANCIS DRAKE BLVD
Practice Address - Street 2:
Practice Address - City:KENTFIELD
Practice Address - State:CA
Practice Address - Zip Code:94904-1418
Practice Address - Country:US
Practice Address - Phone:415-485-3524
Practice Address - Fax:415-485-3507
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-26
Last Update Date:2008-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG43530207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G435300Medicaid
CA00G435300Medicaid
CA00G435301Medicare ID - Type Unspecified