Provider Demographics
NPI:1730109414
Name:WATERS, GORDON BRENT (MD)
Entity Type:Individual
Prefix:MR
First Name:GORDON
Middle Name:BRENT
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 1:120 E CARTER AVE
Mailing Address - Street 2:
Mailing Address - City:BLACKSHEAR
Mailing Address - State:GA
Mailing Address - Zip Code:31516-1561
Mailing Address - Country:US
Mailing Address - Phone:912-449-4426
Mailing Address - Fax:912-449-1059
Practice Address - Street 1:120 E CARTER AVE
Practice Address - Street 2:
Practice Address - City:BLACKSHEAR
Practice Address - State:GA
Practice Address - Zip Code:31516-1561
Practice Address - Country:US
Practice Address - Phone:912-449-4426
Practice Address - Fax:912-449-1059
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA052849207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA08BBQKJMedicare ID - Type Unspecified
GAH51355Medicare UPIN