Provider Demographics
NPI:1104813096
Name:WATERS, MARK (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:
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 1:107 HICKORY HEIGHTS DR
Mailing Address - Street 2:
Mailing Address - City:BRIDGEVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:15017-1077
Mailing Address - Country:US
Mailing Address - Phone:412-319-7688
Mailing Address - Fax:
Practice Address - Street 1:2600 OLD WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:UPPER ST CLAIR
Practice Address - State:PA
Practice Address - Zip Code:15241-2524
Practice Address - Country:US
Practice Address - Phone:412-854-3627
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD045454L207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1280366Medicaid
PA012221LQVMedicare PIN
PA1280366Medicaid
PAF24287Medicare UPIN