Provider Demographics
NPI:1629140561
Name:WATERS, MICHAEL FARRIS (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:FARRIS
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 1:2910 N 3RD AVE # 470
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-4434
Mailing Address - Country:US
Mailing Address - Phone:602-406-6262
Mailing Address - Fax:602-406-6261
Practice Address - Street 1:1 GUSTAVE L LEVY PL FL 12
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-6574
Practice Address - Country:US
Practice Address - Phone:212-241-7076
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ521082084V0102X, 2084N0400X
NY3271132084V0102X, 2084N0400X
CAA78335174400000X
FLME868832084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084V0102XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyVascular Neurology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL279658900Medicaid
FLAG489ZMedicare PIN
I34994Medicare UPIN