Provider Demographics
NPI:1700197977
Name:WATERS, HEATHER ELIZABETH (DO)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:ELIZABETH
Last Name:WATERS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:ELIZABETH WHITE
Other - Last Name:AULTMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1146 EVELYN GANDY PKWY
Mailing Address - Street 2:
Mailing Address - City:PETAL
Mailing Address - State:MS
Mailing Address - Zip Code:39465-3947
Mailing Address - Country:US
Mailing Address - Phone:601-584-4309
Mailing Address - Fax:
Practice Address - Street 1:1146 EVELYN GANDY PKWY
Practice Address - Street 2:
Practice Address - City:PETAL
Practice Address - State:MS
Practice Address - Zip Code:39465
Practice Address - Country:US
Practice Address - Phone:601-584-4309
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-23
Last Update Date:2020-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS21796207Q00000X
FLOS 14505207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
21796OtherMS MEDICAL LICENSE