Provider Demographics
NPI:1902842677
Name:WATERSON, ZACHRY LANE (DO)
Entity Type:Individual
Prefix:
First Name:ZACHRY
Middle Name:LANE
Last Name:WATERSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 BROADWAY
Mailing Address - Street 2:SUITE 150
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46802-1411
Mailing Address - Country:US
Mailing Address - Phone:260-423-2682
Mailing Address - Fax:260-422-4326
Practice Address - Street 1:750 BROADWAY
Practice Address - Street 2:SUITE 350
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46802-1411
Practice Address - Country:US
Practice Address - Phone:260-423-2682
Practice Address - Fax:260-422-4326
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2011-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN0200245A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000222712OtherBLUE CROSS
IN200231240Medicaid
000000015336OtherMPLAN
H25255Medicare UPIN
IN185760NMedicare ID - Type Unspecified