Provider Demographics
NPI:1821046335
Name:WATERS, STANLEY J (MD, PHD)
Entity Type:Individual
Prefix:
First Name:STANLEY
Middle Name:J
Last Name:WATERS
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1673 SHORELINE DR
Mailing Address - Street 2:STE 100
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-6736
Mailing Address - Country:US
Mailing Address - Phone:208-322-0485
Mailing Address - Fax:208-378-8228
Practice Address - Street 1:1673 SHORELINE DR
Practice Address - Street 2:STE 100
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-6736
Practice Address - Country:US
Practice Address - Phone:208-322-0485
Practice Address - Fax:208-378-8228
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-05
Last Update Date:2015-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM6247207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000039400Medicaid
ID71928OtherBLUE CROSS PROVIDER #
ID000010004618OtherBLUE SHIELD PROVIDER #
ID71928OtherBLUE CROSS PROVIDER #
ID1127922Medicare ID - Type UnspecifiedPROVIDER #