Provider Demographics
NPI:1659345411
Name:WATERS, JOHN S (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:S
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 1:72 ALEXANDER AVE
Mailing Address - Street 2:
Mailing Address - City:LAMBERTVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08530-2200
Mailing Address - Country:US
Mailing Address - Phone:609-397-3535
Mailing Address - Fax:
Practice Address - Street 1:72 ALEXANDER AVE
Practice Address - Street 2:
Practice Address - City:LAMBERTVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08530-2200
Practice Address - Country:US
Practice Address - Phone:609-397-3535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04095900207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7859007Medicaid
NJE13327Medicare UPIN
NJ7859007Medicaid