Provider Demographics
NPI:1760452049
Name:WATERS, JEREMY J (MD)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:J
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 1:606 N 3RD AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83864-1594
Mailing Address - Country:US
Mailing Address - Phone:208-263-1435
Mailing Address - Fax:208-263-4580
Practice Address - Street 1:606 N 3RD AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864-1594
Practice Address - Country:US
Practice Address - Phone:208-263-1435
Practice Address - Fax:208-263-4580
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2008-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-9457207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1133322Medicare PIN