Provider Demographics
NPI:1255368023
Name:WATERS, TAMMI M (DO)
Entity type:Individual
Prefix:
First Name:TAMMI
Middle Name:M
Last Name:WATERS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 OLIVE CHAPEL RD STE 124
Mailing Address - Street 2:
Mailing Address - City:APEX
Mailing Address - State:NC
Mailing Address - Zip Code:27502-6766
Mailing Address - Country:US
Mailing Address - Phone:919-727-1850
Mailing Address - Fax:919-727-1851
Practice Address - Street 1:1600 OLIVE CHAPEL RD STE 124
Practice Address - Street 2:
Practice Address - City:APEX
Practice Address - State:NC
Practice Address - Zip Code:27502-6766
Practice Address - Country:US
Practice Address - Phone:919-727-1850
Practice Address - Fax:919-727-1851
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-27
Last Update Date:2019-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT043663207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001436634Medicaid
CT001436634Medicaid
CT080001843Medicare PIN