Provider Demographics
NPI:1750844940
Name:WATERS, CLIFTON
Entity Type:Individual
Prefix:
First Name:CLIFTON
Middle Name:
Last Name:WATERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 DAVIS ST
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21804
Mailing Address - Country:US
Mailing Address - Phone:443-614-9829
Mailing Address - Fax:
Practice Address - Street 1:206 DAVIS ST
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21804
Practice Address - Country:US
Practice Address - Phone:443-614-9829
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-13
Last Update Date:2019-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA20190936172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
0OtherMEDICAL TRANSPORTATION