Provider Demographics
NPI:1861439507
Name:WATERS, EDWIN C (MD)
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:C
Last Name:WATERS
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1515 N HARVARD AVE
Mailing Address - Street 2:SUITE E
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74115-4957
Mailing Address - Country:US
Mailing Address - Phone:918-832-6049
Mailing Address - Fax:918-832-6055
Practice Address - Street 1:12455 E 100TH ST N
Practice Address - Street 2:SUITE 120
Practice Address - City:OWASSO
Practice Address - State:OK
Practice Address - Zip Code:74055-4674
Practice Address - Country:US
Practice Address - Phone:918-274-5510
Practice Address - Fax:918-274-5519
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2011-02-09
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Provider Licenses
StateLicense IDTaxonomies
MO115331207Q00000X
OK25302207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO205336308Medicaid
MOH41941Medicare UPIN
MO205336308Medicaid