Provider Demographics
NPI:1780187302
Name:WATERS, SAMUEL G (MD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:G
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 1:512 FARR SHORES DR
Mailing Address - Street 2:
Mailing Address - City:HOT SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:71913-9622
Mailing Address - Country:US
Mailing Address - Phone:501-765-3191
Mailing Address - Fax:
Practice Address - Street 1:512 FARR SHORES DR
Practice Address - Street 2:
Practice Address - City:HOT SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:71913-9622
Practice Address - Country:US
Practice Address - Phone:501-765-3191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-09
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC-8150207P00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR122903001Medicaid